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Chapter 9

The Kidneys
Therese M. Weber, Michelle L. Robbin and Mark E. Lockhart

Renal Vascular Doppler Ultrasound and interpretation of the study will reduce examina-
tion time, improve study quality, and optimise
Ultrasound is the imaging modality of choice for
diagnostic accuracy. A dedicated quality control pro-
evaluation of the kidneys, especially in patients with
gramme is an important mechanism to assess accuracy
borderline renal function, the incidence of which is
and to review cases in which an incorrect diagnosis
increasing. In comparison with other modalities,
was made. The goal of this review process should be
ultrasound has the distinct advantage of providing
to improve the quality of future studies.
clinically diagnostic information without the need
One common challenge in renal vascular ultra-
for ionising radiation or contrast agents. The combi-
sound is direct visualisation of the proximal renal
nation of spectral, colour, and/or power Doppler is
arteries. Overlying bowel gas may completely obscure
extremely helpful in renal vasculature evaluation.
the renal vascular origins and result in a non-
diagnostic study. To improve the likelihood of a diag-
CLINICAL CONSIDERATIONS nostic study, we request that patients be fasting for at
Common clinical indications for renal ultrasound least 6 to 8 hours, when possible, to decrease bowel
include renal insufficiency and renal failure. Specif- gas. Another limitation is the deep location of the
ically, the request to exclude renal obstruction as native renal vessels, especially in obese patients, and
the aetiology of acute renal failure leads the list. utilisation of appropriate sonographic windows may
Doppler ultrasound is not routinely performed to be helpful. Graded transducer pressure can bring
evaluate acute renal failure but may be prompted the transducer closer to the arteries and simulta-
by certain clinical indicators (Box 9-1) or greyscale neously displace overlying gas. However, the renal
findings. Colour and spectral Doppler is more com- arteries occasionally may not be directly visualised
monly used in the native kidneys for evaluation of despite optimal technique; in some of these technically
unexplained or uncontrolled hypertension caused difficult cases, the identification of segmental arterial
by renal artery stenosis (RAS) or for determination waveform abnormalities may still allow successful
of vessel patency. In hypertensive patients, some diagnosis of RAS.
authors suggest Doppler should be reserved for
those patients with a strong clinical suspicion for Main Renal Artery Evaluation
RAS who are likely to benefit from intervention.1
Doppler evaluation of the renal arteries should not
As will be shown, there are many other vascular
occur without a thorough greyscale examination of
abnormalities than can be demonstrated by Dopp-
the kidneys. Greyscale imaging can provide useful
ler, and these can present with a wide variety of
information about renal size and cortical thickness
symptoms or signs.
and should be part of the initial series of images.
For Doppler image acquisition, a preliminary scan of
TECHNICAL CONSIDERATIONS the abdominal aorta is performed with colour Doppler
Renal Doppler ultrasound can be one of the most in the transverse plane beginning at the level of the
challenging vascular ultrasound examinations. superior mesenteric artery (SMA) to locate the main
Extensive training and experience in performance renal arteries, which typically originate within 2 cm

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194 9 The Kidneys


• Hypertension with clinical concern for renal artery stenosis
• Hypertension uncontrolled by medical therapy
• Hypertension with abrupt onset
• Hypertension after ACE inhibitor
• Hypertension with discrepant renal size on greyscale US
• Audible abdominal bruit
• Patient with aortic aneurysm
• Patient with aortic dissection
FIGURE 9-2 Normal renal arteries. Longitudinal power Doppler
• Patient with renal insufficiency at clinical risk for RAS shows the aorta and both renal artery origins in normal location
• Follow-up of known RAS after vascular therapy (arrows) with appearance termed as a ‘banana peel’.

identify the renal artery origin, the entire main renal

of the SMA (Fig. 9-1). Transverse images may be
artery should be visualised sonographically. Lack of
obtained from a midline approach with the patient
visibility of even a 10 mm segment of main renal artery
supine or rolled into the left lateral decubitus position.
will limit the sensitivity of the direct method for RAS.
The imager can localise the right renal artery passing
This is especially relevant in younger patients in whom
posterior to the IVC then rotate the transducer while
fibromuscular dysplasia is a concern; stenosis in these
maintaining the artery in view. Also, the transducer
patients may not be near the renal artery origins
can be placed longitudinally lateral to the rectus mus-
(described later). As part of the direct Doppler evalu-
cle resulting in a ‘banana peel’ image (Fig. 9-2), in
ation, the peak systolic velocity with angle correction
which the aorta is the banana and the renal artery is
should be measured at the renal artery origin, mid and
the banana skin on each side, being peeled off the
distal artery, and at any region of turbulent disorga-
banana. If the main renal arteries cannot be demon-
nised flow with aliasing on colour Doppler.
strated from the midline approach, a right or left lateral
Accessory renal arteries occur commonly (approxi-
approach is used to follow each artery centrally from
mately 30% of kidneys), but are not always demon-
the renal hilum. Regardless of the technique used to
strated sonographically. In fact, studies suggest that
only 21–41% of accessory renal arteries are visualised
by Doppler evaluation.2,3 This low success rate has
prompted some individuals to argue that sonographic
evaluation for RAS is not sensitive enough as a screening
study. However, Bude et al. found that less than 1% of
accessory renal arteries were the only stenotic artery,4
which essentially negates the significance of not
visualising an accessory renal artery.
As mentioned earlier, the deep location of main
renal arteries often limits their direct evaluation, and
it will drive the choice of transducer. Lower-frequency
transducers will have better sonographic depth pene-
tration, with a trade-off of decreased spatial resolution.
As a general rule, the highest-frequency transducer
FIGURE 9-1 Normal renal arteries. Greyscale transverse image of the that allows good demonstration of the artery and arte-
aorta demonstrates normal origins of the renal arteries (arrows). rial waveform is preferable.

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9 The Kidneys 195

Greyscale visualisation of the renal arteries should A posterior flank approach reduces the distance
be optimised prior to colour and spectral Doppler eval- from the transducer to the segmental arteries. Of note,
uation. Doppler gain should be adjusted for flow detec- the liver and spleen should not be used as a window to
tion by increasing the gain to a level just below the improve visualisation of the kidney, as the vessels are
appearance of colour artifact in adjacent structures. closer to a zero degree angle with the transducer posi-
Pulse repetition frequency, or velocity scale, is the tioned using a more posterior approach. The upper,
frequency of sampling, and under-sampling may interpolar, and lower pole segmental arteries are indi-
underestimate peak velocities. In newer systems, vidually studied. A heel–toe technique is commonly
built-in software can automatically optimise these applied in which one edge of the transducer is angled
parameters, with manual adjustment occasionally into the skin to align the targeted segmental artery flow
required by the sonographer. For spectral Doppler, the as close to the transducer angle of insonation (theta
Doppler gate should be set to include the entire arterial less than 20 degrees) as possible to enhance the signal
lumen and angled to the direction of flow. The angle of quality. This can enhance the definition of the early
insonation should be maintained at 60 degrees or less. systolic peaks. Electronic beam steering can also be
As angulation increases to 80–90 degrees, the confi- used to better align angulation of the insonating beam
dence in the measured velocity decreases, as the cosine to enhance waveform morphology.
of the angle of insonation approaches zero. This yields Characteristics of the spectral Doppler tracing
large differences in measured velocity for a small in normal segmental intrarenal arteries should include
variation in the relative angle of flow. rapid upstroke to an early systolic peak with gentle
decrease in flow velocity during late systole and dias-
Segmental Intrarenal Artery Evaluation tole (Fig. 9-3). Persistent antegrade flow throughout
When the main renal artery is not well seen in its the cardiac cycle should be present without return
entirety, evaluation of the segmental intrarenal arteries to baseline. The resistive index (RI), calculated as:
may allow a non-diagnostic direct examination to
Peak systolic velocity ðPSVÞ  End diastolic velocity ðEDVÞ
become diagnostic for RAS.5,6 We always examine the
Peak systolic velocity ðPSVÞ
segmental arteries even when the main renal
arteries are well seen, because the segmental artery is a common parameter for characterisation of arterial
waveform morphology may be useful in detecting flow. The RI is inversely proportionate to the relative
concomitant renal parenchymal disease. amount of diastolic flow. For instance, an end diastolic

FIGURE 9-3 Normal segmental artery waveform.

Colour Doppler shows normal colour flow without
aliasing. Spectral Doppler shows rapid upstroke
and smooth velocity decline with persistent flow
throughout the cardiac cycle.

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196 9 The Kidneys

velocity that is 20% of the peak flow will result in RI of

0.80. The upper limit of RI in normal adults has been
reported as less than 0.70,7 but concern for pathology
is not often raised until the RI is 0.75–0.80, or higher.
Furthermore, the RI may be affected by other factors IN
such as heart rate, Valsalva, and arterial compliance.
In fact, RIs greater than 0.70 are common in elderly A
patients.8 The impact of systemic vascular disease in
chronic renal dysfunction is significant. It has been
recently suggested that the renal RI measurement does
not distinguish local from systemic vascular damage. IL
A new potential ultrasound measurement, the differ-
ence of RIs between the spleen and kidney, may allow
more specific evaluation of renal parenchymal dam-
age.9 However, this study has not yet been further val-
idated or widely applied in practice.
FIGURE 9-4 Renal arterial branching. Line drawing demonstrates the
normal arterial branching from the main artery (M) to the segmental (S),
interlobar (IN), arcuate (A), and interlobular (IL) arteries.
Anatomy of the Native Kidneys
Segmental branches arise from the dorsal and ventral
The renal arteries typically arise from the abdominal
rami and run along the infundibulae before dividing
aorta caudal to the level of the SMA. The right renal
into interlobar arteries. These interlobar arteries
artery usually originates from the anterolateral aspect
course between the pyramids, and then branch into
of the aorta, while the left renal artery usually origi-
arcuate arteries, which run along the bases of medul-
nates from the posterolateral aspect. As noted earlier,
lary pyramids. Within the cortex, small interlobular
approximately 30% of patients will have more than
arteries course outward toward the surface of the
one renal artery.10 Accessory renal arteries usually
arise from the aorta caudal to the main renal artery
to supply the renal lower pole, but occasionally will
course cranially to supply the upper pole. Rarely, VENOUS ANATOMY
accessory arteries may arise from an iliac artery or even The renal venous anatomy parallels the arterial anat-
the SMA. Renal anomalies such as horseshoe or pelvic omy. Normal venous flow on spectral Doppler has a
kidney almost always have multiple renal arteries, relatively low velocity. Its waveform is driven by right
which may arise from the aorta or iliac arteries. atrial activity. Accessory left renal veins are less fre-
The main renal artery divides into dorsal and ven- quent than accessory renal arteries; however, accessory
tral rami that course posterior and anterior to the renal right renal veins are quite common. Left venous anom-
pelvis. The anterior and superior aspects of the kidney alies may be seen in approximately 11% of patients.11
are typically supplied by the larger ventral division. Variants most commonly include the retroaortic and
The posterior and inferior portions of the kidney are circumaortic renal veins (Fig. 9-5), and these may be
supplied by the smaller dorsal division. The junction clinically relevant even beyond filter placement. In a
of these ventral and dorsal divisions creates a relatively recent study by Karazincir et al., the incidence of retro-
avascular plane (Brodel’s line), which is the preferred aortic left renal vein was found to be significantly
track of percutaneous nephrostomy placement, and higher in patients with varicocele, compared with
should be considered when performing a renal biopsy. controls12 (see Fig. 9-24 in the varicocele section).
The branching pattern of the renal arteries pro- The left renal vein receives drainage from the infe-
gresses symmetrically to the renal cortex (Fig. 9-4). rior phrenic, capsular, ureteric, adrenal and gonadal

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9 The Kidneys 197

incidence varies greatly. Renal vein varices may be

secondary to renal vein thrombosis or portal hyper-
tension, or they may be idiopathic. Like varicoceles,
renal varices are more common on the left than the
right. In cases of left renal vein thrombosis, the varices
may extend through the inferior phrenic, adrenal,
gonadal, and ureteric veins. On the right, the only
common branch is the ureteric vein.

Renal Failure and Obstruction

Doppler can play a supportive role in the diagnosis or
exclusion of renal obstruction in patients with acute
renal failure. Identification of a dilated renal collecting
system is fairly easy with ultrasound. The difficulty,
A however (in the absence of prior examinations) is the
differentiation of an acutely obstructed high-pressure
system versus that of a low-pressure, chronically
dilated system. It has been suggested that elevated
resistive index may help differentiate between severe
acute urinary obstruction and chronic dilatation.13–15
The RI of the obstructed kidney may be elevated rela-
tive to the normal contralateral kidney. An RI difference
of greater than 0.10 between the non-obstructed and
obstructed kidney is the suggested threshold for diag-
nosis of acute obstructed uropathy. However, intra-
renal autoregulatory hormonal systems counteract
the mechanical effect of the high-pressure collecting
system pressing upon the parenchyma. This rapidly
modifies the resistance to flow, reducing sensitivity
of the test. In the setting of partial obstruction or
less severe obstruction, this finding also lacks sensitiv-
B ity.16,17 As an aside, in cases of chronic renal disease
FIGURE 9-5 Renal vein variants. Line drawings demonstrate the without obstruction, elevated RI > 0.80 has been
anatomic appearance of a retroaortic (A), and circumaortic (B) left shown to be associated with worsening renal function
renal vein. and mortality.18
Another Doppler tool to assist in the evaluation of
veins and flows across midline into the normal IVC. In urinary obstruction can be performed within the
patients with a left-sided IVC, the left common iliac bladder. In cases with suspected renal obstruction,
vein continues cranially as the left IVC and drains into sonographic evaluation for a ureteral jet should be a
the inferior aspect of the left renal vein. The right renal component of the renal ultrasound examination
vein is shorter than the left and courses obliquely into (Fig. 9-6). Although entry of urine into the urinary
the IVC. The right renal vein receives capsular and ure- bladder is not synchronous, demonstration of three
teric veins; however, the right inferior phrenic and or more ureteral jets by Doppler on one side without
gonadal veins enter directly into the IVC. Valves may a single pulse of flow from the contralateral side
be present within the renal veins, but their reported implies obstruction of the non-pulsing ureter.

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198 9 The Kidneys

FIGURE 9-6 Normal ureteral jet. Transverse colour Doppler image

shows a linear ‘jet’ of colour projecting into the bladder lumen. This
represents the rapid flow of urine into the bladder secondary to
ureteral peristalsis.

Renal Infection
Renal ultrasound examination is not routinely
requested in cases of renal infection and ultrasound
findings are quite variable in these cases. Renal paren-
chymal infection may be global or focal and the route
of spread may be ascending or blood-borne. More B
common ultrasound findings, not consistently seen, FIGURE 9-7 Renal calculus. (A). Greyscale ultrasound shows an
are enlargement or altered echogenicity of the affected echogenic focus in the calyceal region of the renal lower pole.
kidney. The presence of perinephric fluid would add However, there are other echogenic foci in this region, which may
represent additional stones. (B) Colour Doppler confirms presence
confidence. Demonstration of altered blood flow, with
of two calculi with visualisation of ‘twinkle’ artifact.
reduction of Doppler indices and perfusion in an
affected renal segment adds confidence to the diagno-
sis of focal pyelonephritis.
rather than bright echogenic renal hilar adipose tissue.
This technique should be used to demonstrate the
Nephrolithiasis presence of the stone, not to measure size of the stone.
This is an especially useful adjunct to evaluate for dis-
Colour Doppler evaluation should be a routine com-
tal ureteral stone with endovaginal technique when a
ponent of the renal ultrasound examination when
dilated upper renal collecting system is identified in
nephrolithiasis is suspected. Greyscale alone has poor
pregnancy (Fig. 9-8).
sensitivity for small renal stones. Using colour
Doppler, twinkle artifact19 can increase confidence
in the presence of renal, ureteral or bladder stones
Renal Tumours
(Fig. 9-7). The irregular surface of the calculus causes
a Doppler shift which manifests as a noisy colour and Greyscale ultrasound is the primary sonographic tech-
spectral signal. This helps confirm that a bright echo- nique for detection of a renal tumour, but colour
genic focus within the renal hilum is indeed a calculus, Doppler can provide additional information for

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9 The Kidneys 199

FIGURE 9-8 Ureteral calculus. (A) Longitudinal greyscale ultrasound with sepia colour encoding shows the linear anechoic distal ureter with
a shadowing echogenic focus. (B) Colour Doppler confirms the presence of a ureteral stone with ‘twinkle’ artifact.

surgical planning. Colour Doppler may be useful in Renal Vascular Abnormalities

intraoperative ultrasound examinations when trying
to precisely identify the depth of tumour invasion RAS/HYPERTENSION
(Fig. 9-9). Colour Doppler may also be helpful to Renal vascular disease is an uncommon cause of
confirm the extent of renal cell tumour invasion into hypertension; however, it is potentially curable, and
the inferior vena cava (Fig. 9-10). This may be helpful is most commonly considered in young adult patients
for surgical planning by clearly delineating the cranial with abrupt onset of hypertension and uncontrolled or
extent of tumour. Colour Doppler can help confirm rapidly accelerating hypertension. Stenotic renovascu-
whether tumour involves the intrahepatic portion of lar disease has two primary aetiologies, atherosclerosis
the IVC, which would significantly increase the com- and fibromuscular dysplasia. In older patients the
plexity of surgical removal. The presence of arterial underlying aetiology is most frequently renal ostial
signal within the thrombus confirms it as tumour atherosclerotic disease. The second most common
thrombus (versus bland thrombus). aetiology is fibromuscular dysplasia, which is an

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200 9 The Kidneys

FIGURE 9-9 Renal tumour. (A) Longitudinal greyscale ultrasound demonstrates a solid exophytic mass arising from the renal lower pole.
(B) Colour Doppler clearly depicts the margins of the tumour and the presence of vessels along its periphery. This allows better definition of
the depth of invasion to aid in surgical planning.

FIGURE 9-10 Renal tumour venous extension into the IVC. (A) Greyscale image shows expansion of the infrahepatic IVC by a solid lesion
(calipers). (B) The addition of colour Doppler helps delineate the cranial extent of the tumour thrombus.

uncommon disorder seen most frequently in younger no significant difference in two randomised cohorts
women, and unlike atherosclerotic lesions, generally of patients between medical management versus stent
responds well to angioplasty.20,21 The role of imaging therapy for the treatment of RAS. The long-standing
is influenced by the potential benefit of intervention.1 ischaemic insult to the renal parenchyma with
Although renal artery stenosis can be identified with associated cholesterol crystal embolisation causes
imaging, recent studies suggest that simply the iden- significant damage that does not benefit from reestab-
tification of stenosis does not justify invasive treat- lishment of more normal flow through the main renal
ment by stenting. Two recent randomised trials, artery. Evaluation of renal perfusion in the presence
including the ASTRAL study, have shown no benefit of stenosis may be more useful to select patients
to revascularisation of atherosclerotic lesions, with who will benefit from intervention. Some authors
regards to either blood pressure or renal func- have suggested Doppler measurement of resistive
tion.22,23 The ASTRAL study found that there was index, with high resistance behind a stenosis

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9 The Kidneys 201

indicating significant parenchymal damage. A patient

with a low-resistance tardus-parvus waveform may,
however, still benefit. Recent advances in MR perfu-
sion technology allow measurement of perfusion/dif-
fusion and tissue oxygenation, making it more
accurate in this prediction.
The results of the ASTRAL trial have stirred much
controversy in the literature. Recent reviews suggest
there still may be a role for imaging and stenting in
patients with acute-onset hypertension or rapidly
accelerating hypertension. This is suggested for
those patients in whom parenchymal renal damage
has not yet advanced to the point of irreversible
hypertension. FIGURE 9-11 Renal artery stenosis. Turbulent flow may appear as
Although CT and MR angiography are probably ‘aliasing’ on colour Doppler (arrow) as elevated velocities wrap
around into the lower colour scale.
used more frequently for evaluation of RAS in most
institutions, ultrasound is an ideal initial screening
study because of the lack of ionising radiation or velocity is beyond the scale limits and wraps into the
contrast administration. In ultrasound programmes other end of the colour scale (Fig. 9-11), and should
experienced with renal vascular ultrasound, recent lead to close evaluation with spectral Doppler in this
studies have shown the sensitivity and specificity of area. Spectral Doppler confirmation of RAS relies pri-
Doppler ultrasound for RAS is up to 95% and 90%, marily on demonstration of elevated PSV and demon-
respectively.24 stration of disturbed flow distal to the lesion.
There are two main methods for sonographic Varying criteria have been suggested for the direct
detection of RAS: direct demonstration of RAS and indi- spectral Doppler diagnosis of RAS, which has resulted
rect assessment of the downstream effect of the stenosis in controversy. A PSV of greater than 200 cm/s
on the segmental renal arteries25 (Box 9-2). Greyscale (Fig. 9-12) has been suggested for Doppler diagnosis
findings are first considered and a renal length disparity of 60% diameter reduction of the renal artery.27,28 In
greater than 2 cm with cortical thinning should raise a recent meta-analysis, PSV was the best critical
concern for the diagnosis. Visualisation of turbulent factor in diagnosing RAS, with sensitivity and specific-
flow within the renal artery on colour Doppler suggests ity of 85% and 92%, respectively.29 The ratio of the
an area of stenosis.26 Increased velocities in the focal renal artery PSV to the aortic PSV (RA/Ao) is another
area of stenosis may appear as colour aliasing if the criterion suggested for diagnosis of RAS. An RA/Ao
PSV ratio of greater than 3.5:1 (Fig. 9-13) suggests
BOX 9-2 SUMMARY OF DOPPLER significant RAS, yielding 91% sensitivity and 91%
PARAMETERS FOR DIAGNOSIS OF RAS specificity.30 An elevated ratio of peak renal artery
• Elevated peak systolic velocity (PSV) systolic velocity to distal renal artery systolic velocity
• Elevated PSV ratio of renal artery relative to aorta
has also been suggested as a criterion for diagnosis
of RAS.31,32 One study of 187 renal arteries with
• Focal aliasing in renal artery on colour Doppler due to
angiographic correlation also showed an absolute
turbulent flow
renal interlobar PSV of less than 15 cm/s resulted in
• Asymmetry of segmental artery resistive indices relative to 87% and 91% sensitivity and specificity, respectively,
contralateral kidney
for Doppler diagnosis of 50% stenosis.32 Jian-Chu
• Segmental artery loss of early systolic peaks et al. have recently studied the impact of atherosclero-
• Segmental artery delayed systolic acceleration (tardus) sis and age on Doppler sonographic parameters for
• Segmental artery low peak velocity (parvus) the diagnosis of RAS and suggest that use of the
renal-aortic ratio and renal-interlobar ratio diagnostic

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202 9 The Kidneys

FIGURE 9-12 Renal artery stenosis. Duplex Doppler shows a region of colour Doppler aliasing (Doppler gate), and the peak systolic velocity
measures 528 cm/s, which is above the 200 cm/s threshold.

thresholds differ in patients older versus younger than systolic peak. In blunted waveforms, this early peak
46 years. Other sonographic criteria were not sub- may be absent, and the measurement should extend
stantially affected by patient age in their study.33 from onset of systole to the first point of deflection.36
The indirect method of RAS assessment of segmen- The presence of the tardus–parvus waveform morphol-
tal renal artery waveforms becomes important when ogy is helpful in the diagnosis of severe RAS; however,
the entire length of the main renal artery cannot be its absence does not exclude RAS.37 The tardus–parvus
directly seen with ultrasound. Stavros et al.5,34 have spectral waveform is defined by the slow upstroke (the
suggested that normal intrarenal waveform morphol- tardus) and spectral broadening with blunting of the
ogy with early systolic peak in the upper, interpolar, systolic peak (the parvus) (Fig. 9-15). It is important
and lower pole segmental renal arteries may be used to note that in patients with atherosclerotic disease,
to adequately exclude significant RAS. This normal vessel compliance may be diminished, making the
compliance peak (Fig. 9-14) is not present when there tardus–parvus waveform morphology less obvious.38
is flow-limiting stenosis in the proximal artery, A less common criterion suggested for diagnosis of
although others have found this sign less sensitive.35 RAS is excessive difference in RI of the two kidneys
Another criterion of RAS is prolonged acceleration ( 0.07).5,39 For lesser degrees of stenosis, the abnor-
time of greater than 0.07 second. Acceleration time is mal kidney will show lower RIs beyond the point of
the time interval from onset of systole to the early stenosis due to post-stenotic dilatation. However, as

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9 The Kidneys 203

FIGURE 9-13 Renal artery stenosis. (A) Duplex Doppler of renal artery demonstrates borderline peak systolic velocity, 199 cm/s. (B) Spectral
Doppler waveform of the aorta shows peak velocity is 59 cm/s. The calculated renal artery-aortic peak systolic velocity ratio of 3.72 is above the
3.5 threshold, suggesting significant stenosis.

the stenosis becomes more flow limiting, there may patients without clinical suspicion of restenosis, 22
not be persistence of flow throughout the cardiac patients had elevated PSV of greater than 200 cm/s
cycle, resulting in a high RI. and had significantly worsened rate of renal function
Another potential application of Doppler is for decline than those patients with PSV of less than
follow-up to assess for restenosis in patients after stent 200 cm/s.40 In 6 of 11 of these patients with this
placement for RAS (Fig. 9-16). This may be ordered criterion who underwent angiography despite the lack
due to worsening renal function or even when clinical of clinical suspicion, all had restenosis of greater than
signs of restenosis are absent. In a study of 64 stented 70% at angiography.

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204 9 The Kidneys

FIGURE 9-14 Normal segmental artery compliance

peak. Duplex Doppler shows an early systolic small
peak (arrows) at the point of peak systolic velocity
in the absence of upstream stenosis.

FIGURE 9-15 Renal artery stenosis. On duplex

Doppler of a lower pole segmental artery, the
delayed systolic acceleration (tardus) and small
waveform (parvus) are consistent with upstream
stenosis and further main renal artery evaluation
is warranted if a stenosis has not yet been
directly visualised.

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9 The Kidneys 205

FIGURE 9-16 Restenosis after stenting. (A) Duplex Doppler of right main renal artery in stented patient with recurrent hypertension shows
elevated PSV in region of colour aliasing. (B) Spectral Doppler of a segmental renal artery demonstrates tardus-parvus waveform.


Intrarenal vascular disease such as polyarteritis nodosa Complete thrombosis of the native renal artery is
(PAN), Wegener’s granulomatosis, and scleroderma uncommon except in the setting of stents or bypass
cannot routinely be diagnosed with renovascular grafts for abdominal aortic aneurysm repair, or in
Doppler ultrasound. Renal artery thrombosis, emboli- the setting of trauma. In the setting of trauma, there
sation, ischaemia and infarction should be detectable may be avulsion of the renal artery with or without
by Doppler ultrasound. Visible structural renal vascu- extravasation. Traumatic dissection of the artery can
lar lesions may include renal artery aneurysm (RAA) or also result in arterial occlusion, and can have similar
arteriovenous malformation. Doppler findings as renal artery avulsion. Asymmetric

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206 9 The Kidneys


Arteriovenous fistula in the native kidney is rare except
in cases of prior renal biopsy and will not be suspected
sonographically if colour or power Doppler is not
evaluated. Colour or power Doppler characteristically
will show a large tortuous cluster of vessels. Spectral
Doppler waveforms of the renal arteries feeding the
fistula will show high velocity and low resistance
(Fig. 9-19). The main renal vein may be dilated and
arterialised waveforms may be found in veins near
the fistula (Fig. 9-20).
FIGURE 9-17 Renal artery thrombosis. No parenchymal flow is
visible in the lower pole (arrows) on power Doppler. When there is
absence of normal flow on routine colour Doppler, then power VENOUS DISEASE
Doppler should be performed due to its higher sensitivity for
Renal Vein Thrombosis
slow flow.
Renal vein thrombosis (RVT) of the native kidneys is
seen more commonly in the paediatric population
lack of flow may involve the entire kidney or a seg- than in adults. In adults, the underlying aetiology
ment, dependent on the level of the abnormality. Col- may include dehydration and nephrotic syndrome,41
our Doppler can show a perfusion defect, but power hypercoagulable state, or trauma to the renal vein.
Doppler is often used to characterise any slow flow Visualisation of renal vein flow with Doppler is critical
in this region. If no flow is identified, optimisation in patients with clinical suspicion for acute RVT. It is
of the Doppler settings should be performed using important to demonstrate the entire renal vein before
the contralateral kidney prior to an additional insona- excluding renal vein thrombosis because the native
tion of the affected kidney. kidney may develop collaterals quickly.
A regional lack of power Doppler flow in the renal The diagnosis of RVT is based upon demonstration
parenchyma with wedge-shaped appearance suggests of thrombus filling the renal vein (Fig. 9-21) or non-
segmental infarction (Fig. 9-17). Search for other sim- occlusive thrombus surrounded by venous flow. In
ilar abnormalities in the contralateral kidney or other some cases, the vein may be expanded by the throm-
organs should be performed since this may be due to bus. The absence of flow in the renal vein without
showering of emboli from a remote source. demonstration of thrombus may suggest RVT;
however, demonstration of low-level colour signal
within the vein on Doppler does not exclude the pos-
RENAL ARTERY ANEURYSM sibility of non-occlusive or occlusive renal vein throm-
The diagnosis of renal artery aneurysm or pseudo- bus. Monophasic venous waveforms are abnormal but
aneurysm is most commonly made by CT or MRI. not specific for RVT.42 Because of the potential
However, there are findings on Doppler that may be for thrombus to extend cranially within the IVC
seen in this abnormality. It may appear as a vascular (Fig. 9-22) and the effect on clinical management,
structure that is fusiform, eccentric, and saccular. the IVC should be imaged as part of the sonographic
RAA commonly arise from a branch point within the examination when evaluating for RVT.
artery. On colour Doppler, there may be circular flow Renal vein thrombus may also be seen in
with a ‘yin-yang’ appearance (Fig. 9-18). A portion of patients with renal cell carcinoma if there is tumour
the aneurysm may be thrombosed. It is common for extension into the renal vein. In these cases arterial
RAA to have peripheral calcifications, and these may flow may be seen within the thrombus on spectral
limit sonographic evaluation of central flow. Doppler.

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FIGURE 9-18 Renal artery aneurysm. (A) Split image shows anechoic round structure on greyscale with flow on colour Doppler. The circular flow
on colour Doppler (arrows), termed the ‘yin-yang’ sign, can be seen with aneurysm or pseudoaneurysm. (B) On angiography, the typical round
vascular structure of an aneurysm is confirmed.

FIGURE 9-19 Arteriovenous fistula. Spectral Doppler

shows high-velocity pulsatile arterial flow with low
resistance near the renal hilum.

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208 9 The Kidneys

FIGURE 9-20 Arteriovenous fistula. (A) Spectral Doppler demonstrates arterialised venous flow with high velocities and low resistance. (B) CT
angiography shows early enhancement of right renal vein (arrow), compared with the left renal vein.

Nutcracker Syndrome (Fig. 9-23) and high venous diameter ratio as described
The ‘nutcracker’ phenomenon results from compres- in recent literature.43 Due to the complexity of the
sion of the left renal vein between the superior mesen- potential surgical repair, measurement of a pressure gra-
teric artery and the aorta and may lead to left renal vein dient between the IVC and the left renal vein may be
hypertension, haematuria, and varix formation. It is needed as confirmation before clinically significant
important to remember that a distended left renal vein renal vein compression is diagnosed. Visualisation of
may be seen in some of the normal population by CT, blood from the ureteral orifice on retrograde uretero-
MR, or ultrasound. Therefore, other criteria should scopy may also be supportive. Colour flow Doppler
be applied, including a high Doppler velocity ratio may provide noninvasive evidence of renal vein

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9 The Kidneys 209

FIGURE 9-21 Renal vein thrombus. On colour

Doppler, low-level echoes fill the left renal vein
with absence of complete Doppler flow filling of
the lumen (arrow).

and is more common on the left due to anatomical

factors of angle of insertion of the gonadal vein into
the left renal vein and potential for compression of
the left renal vein by the SMA. The primary type of
varicocele is associated with incompetent valves,
and the secondary type is associated with increased
venous pressure due to obstructed venous outflow.
Isolated right varicocele is uncommon and should
warrant further evaluation of the right retroperitoneal
area and kidney to exclude a right renal hilar mass or
adenopathy compressing venous outflow. Diagnosis
of varicocele is made on testicular ultrasound exami-
nation when the veins in the spermatic cord area
FIGURE 9-22 Renal vein thrombus. Greyscale image of the right renal are dilated to greater than 2 to 3 mm in diameter
vein shows linear thrombus (arrow) extending into the IVC. In this (Fig. 9-24). Rarely, the varix may be intratesticular
patient, the thrombus was mobile during cardiac pulsations, in location. In some cases, colour Doppler of
worrisome for potential subsequent embolisation.
the dilated veins may show intraluminal thrombus.
Reversal of venous flow at rest with increased rever-
compression with peak velocity ratio greater than 5:1 sed flow during Valsalva is suggestive of the diagnosis,
when collateral veins are demonstrated. On CT, there but in some patients there may only be reversal
may be a sharp change in venous calibre as the vein during Valsalva.44 Techniques used to improve detec-
crosses the SMA, usually with a ‘beaked’ appearance. tion of varicocele include Valsalva or standing posi-
tion. As noted earlier, a recent study by Karazincir
Varicocele Formation et al. showed the incidence of retroaortic left renal
Varicocele is dilatation of the pampiniform venous vein was significantly higher in patients with varico-
plexus seen on testicular ultrasound examination, cele compared with controls.12

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210 9 The Kidneys

FIGURE 9-23 Renal vein nutcracker. In a patient with unexplained haematuria, spectral Doppler of the (A) preaortic left renal vein demonstrates
normal low-velocity flow, 8 cm/s. (B) As the vein crosses between the aorta and SMA (Doppler gate), there is visible narrowing with elevated peak
systolic velocity, 103 cm/s.

vascular ultrasound is dependent on the volume of

Summary cases, as well as the skill and experience of the
Ultrasound plays an important role in the diagnosis sonographers and sonologists interpreting the exami-
and management of renal disease. Ultrasound also nation. The high attention to detail required in per-
plays an extremely important role in the initial forming and interpreting renal vascular ultrasound
evaluation for RAS. The quality and accuracy of examinations will continue to limit its widespread

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9 The Kidneys 211

FIGURE 9-24 Varicocele. (A) Colour Doppler shows dilatation and increased flow within the vessels (arrows) of the spermatic cord and scrotum
during Valsalva measuring greater than 3 mm diameter. In the setting of borderline findings, standing position of the patient may accentuate the
finding. (B) CT in the same patient shows retroaortic left renal vein (black arrow).

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