Genitourinar y Imaging • Original Research

Beland et al.
Renal Function in Chronic Kidney Disease

Genitourinary Imaging
Original Research

Renal Cortical Thickness

Measured at Ultrasound: Is It
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Better Than Renal Length as an

Indicator of Renal Function in
Chronic Kidney Disease?
Michael D. Beland1 OBJECTIVE. The purpose of our study was to determine whether there is a relationship
Nicholas L. Walle1 between renal cortical thickness or length measured on ultrasound and the degree of renal
Jason T. Machan2 impairment in chronic kidney disease (CKD).
John J. Cronan1 MATERIALS AND METHODS. From October to December 2007, 25 patients (13
men and 12 women, mean age 73 years) were identified who had CKD but were not on di-
Beland MD, Walle NL, Machan JT, Cronan JJ alysis. The patients were from a single institution and had undergone renal ultrasound and at
least three serum creatinines within 90 days. The lowest creatinine was used for estimated
glomerular filtration rate (eGFR) calculation using both the Cockcroft-Gault (CG) and the
Modification of Diet in Renal Disease Study (MDRD) equations. Ultrasounds were consen-
sus reviewed by three radiologists (2 attendings and a resident) blinded to specific renal func-
tion. Cortical thickness was measured in the sagittal plane over a medullary pyramid, per-
pendicular to the capsule. Length was measured pole-to-pole. Linear regression was used for
statistical analysis.
RESULTS. Mean cortical thickness was 5.9 mm (range, 3.2–11.0 mm). Mean length was
10 cm (7.2–12.4 cm). Mean minimum serum creatinine was 2.1 mg/dL (1.1–6.1 mg/dL).
Mean eGFR using CG was 34.8 mL/min (10.6–99.4 mL/min) and 36 mL/min (8–66 mL/
min) using MDRD. There was a statistically significant relationship between eGFR and cor-
tical thickness using both CG (p < 0.0001) and MDRD (p = 0.005). There was a statistical-
ly significant relationship between CG and length (p = 0.003) but not between MDRD and
length (p = 0.08).
CONCLUSION. Cortical thickness measured on ultrasound appears to be more closely
related to eGFR than renal length. Reporting cortical thickness in patients with CKD who are
not on dialysis should be considered.
Keywords: chronic kidney disease, estimated glomerular

filtration rate, renal cortex, renal failure, ultrasound
DOI:10.2214/AJR.09.4104
Received December 10, 2009; accepted after revision
January 21, 2010.
WEB
This is a Web exclusive article.
1
Department of Diagnostic Imaging, Rhode Island
Hospital, Warren Alpert Medical School of Brown
University, 593 Eddy St., Providence, RI 02903. Address
correspondence to M. D. Beland (mbeland@lifespan.org).
2
Departments of Biostatistics and Research, Orthopaedics,
and Surgery, Rhode Island Hospital, Warren Alpert Medical
School of Brown University, Providence, RI.
AJR 2010; 195:W146–W149
0361–803X/10/1952–W146
© American Roentgen Ray Society
T
raditional teaching is that renal
length correlates with renal func-
tion in chronic kidney disease
(CKD), and therefore bipolar re-
nal lengths are almost always reported at renal
ultrasound [1]. Previous studies have shown
that renal volume calculated at ultrasound is a
more exact measurement of a functioning kid-
ney than renal length [2, 3]. A more recent
study showed that kidney length and volume
significantly correlated with estimated glomer-
ular filtration rate (eGFR) in the elderly, but
kidney length has a low specificity in predict-
ing renal impairment [4]. However, measuring
the true kidney volume at ultrasound is diffi-
cult. Estimates of volume can be made on the
basis of the ellipsoid formula, but this method
has an inherent defect because the kidney is
not actually ellipsoid [5]. In addition, the ellip-
soid volume would include the central sinus fat
that does not contain functioning renal tissue
and does vary from patient to patient. These
factors likely contributed to the findings in a
recent study that showed a positive, but weak
association between sonographically deter-
mined kidney volume and various indices of
glomerular filtration rate (GFR) [6].
A recent study showed renal volume, and
specifically cortical volume, measured at CT
had a strong positive relationship with renal
function [7]. Additional studies have shown
total renal volumes obtained at CT relate
to renal function [8, 9]. However, there are
drawbacks to using CT, including increased
cost and radiation exposure. In addition, Wi-
djaja et al. [8] showed a significant corre-
lation between ultrasound-measured renal
length and CT-measured renal volume.
In patients with CKD, the renal cortical
echogenicity increases at ultrasound [10].

W146 AJR:195, August 2010

 Renal Function in Chronic Kidney Disease

In addition, the renal cortex often becomes Fig. 1—75-year-old

woman with chronic
thinned [11]. Often this finding occurs with a kidney disease.
normal bipolar renal length and an increase Longitudinal ultrasound
in the relative amount of central sinus fat. To image of right kidney
the best of our knowledge, a relationship be- shows cortical
thickness measured
tween renal function and cortical thickness perpendicularly from
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has not been well established at ultrasound. outer margin of kidney

The purpose of our study was to determine to corticomedullary
junction (arrow).
whether there is a relationship between renal Measurement is 0.46 cm.
cortical thickness or length measured at ul-
trasound and the degree of renal impairment
in CKD using two widely accepted computa-
tional methods of estimating GFR.

Materials and Methods

Patient Selection
This retrospective study was approved by curvilinear transducer (Logiq 9, GE Healthcare). by three authors (a radiology resident (PGY-4) and
our institutional review board and is HIPAA The examinations were retrospectively reviewed two radiology attending physicians specializing in
compliant. A search was performed of our hospital at a PACS workstation (Centricity, GE Healthcare) ultrasound with 3 and 27 years of experience). All
electronic medical record for patients with the
clinical diagnosis of CKD who were not on dialysis TABLE 1:  Study Population
and also had undergone renal ultrasound over a Minimum Maximum Mean
3-month period from October 2007 to December Patient Age Creatinine Creatinine Creatinine MDRD Mean Renal Mean Cortical
2007. This search was further narrowed to patients No. Sex (y) (mg/dL) (mg/dL) (mg/dL) eGFR CG eGFR Length (cm) Thickness (cm)
who had at least three serum creatinines and weight 1 F 43 6.1 11.5 8.63 7.53 10.72 9.8 0.56
recorded within 90 days of the ultrasound. Patients
2 M 90 1.2 1.8 1.42 56.91 43.29 10.7 0.86
with hydronephrosis were excluded. Twenty-five
patients (13 men and 12 women, mean age, 73 3 M 83 2.7 7.1 4.67 22.70 16.51 10.15 0.61
years; age range 26–90 years) met these criteria 4 F 69 3.5 4.1 3.89 12.95 21.57 9.7 0.70
and constitute the study population. 5 F 84 2.1 3.1 2.59 22.45 19.43 9.7 0.56
6 F 68 1.7 1.9 1.82 29.93 25.43 7.15 0.39
Estimation of Renal Function
The lowest creatinine performed within 90 days 7 M 59 1.8 3.8 2.76 38.77 55.79 9.55 0.82
of the ultrasound was used for eGFR calculations. 8 F 65 1.2 1.9 1.60 45.16 51.03 11.85 0.77
The lowest creatinine was chosen because it 9 F 85 1.1 3.3 2.07 47.24 35.67 9.45 0.64
represents the best recorded renal function during
10 M 26 1.7 7.3 3.25 48.96 99.38 12.4 1.10
the study period and helps to minimize the
influence of superimposed acute on chronic renal 11 M 82 1.5 5.6 3.39 44.78 39.07 11.25 0.64
insufficiency [10]. The Cockcroft-Gault (CG) 12 F 90 1.2 2.6 1.79 42.17 21.81 9.5 0.46
and the Modification of Diet in Renal Disease 13 M 83 1.5 2.7 2.15 44.67 56.80 11.45 0.75
Study (MDRD) equations were used for eGFR
14 M 74 1.6 2.6 2.03 42.42 46.01 10.1 0.86
calculation, as follows [12]:
The CG equation is eGFR = (140 − age) × 15 F 75 1.9 2.9 2.42 25.76 25.33 8.5 0.47
(Weight in kg) × (0.85 if female) / (72 × Cr) where 16 F 84 2.8 3.4 3.16 16.10 18.50 7.7 0.28
Cr is creatinine. 17 F 78 1.8 6.4 3.97 27.23 37.29 9.55 0.49
The equation for Modification of Diet in
18 M 83 1.3 2.0 1.53 52.68 40.77 11.9 0.46
Renal Disease (MDRD) for isotope dilution–
mass spectrometry (ID–MS)-traceable creatinine 19 M 75 1.7 3.1 2.53 39.45 33.78 10.15 0.54
measurements is GFR (mL/min/1.73 m2) = 175 × 20 F 70 5.7 6.6 6.20 7.35 12.33 10.9 0.34
(Scr) −1.154 × (Age) −0.203 × (0.742 if female) × (1.212 21 M 76 2.6 5.7 3.92 24.12 19.01 8.45 0.41
if African American) (conventional units). Scr is
22 M 87 1.2 3.2 1.77 57.29 48.06 8.75 0.77
serum creatinine.
23 M 42 1.2 4.6 2.77 66.33 45.73 10.65 0.67
Ultrasound Interpretation 24 F 85 1.1 2.2 1.68 47.21 34.00 10.0 0.61
All renal ultrasound studies were performed in 25 M 69 2.9 3.5 3.24 21.68 17.85 10.0 0.38
the inpatient setting at our tertiary care hospital.
Note—eGFR = estimated glomerular filtration rate, MDRD eGFR = Modification of Diet in Renal Disease study
The examinations were performed using standard for isotope dilution–mass spectometry traceable creatinine measurements, CG eGFR = Cockcroft-Gault
gray-scale B-mode imaging with a 3.5-MHz equation. See Materials and Methods section for calculation of MDRD eGFR and CG eGFR.

AJR:195, August 2010 W147


measurements were made by consensus agreement.
Renal lengths were measured as the greatest pole-
to-pole distance in the sagittal plane. The renal
cortical thickness was measured in the sagittal
plane at the level of the mid kidney as described
by Moghazi et al. [11]. The measurement was taken
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over a medullary pyramid, perpendicular to the
capsule as the shortest distance from the base of
the medullary pyramid to the renal capsule (Fig. 1).
The readers were blinded to specific renal function,
additional imaging, or any additional clinical
information at the time of image review. Cortical
thickness and length were measured bilaterally.
Statistical Analysis
The data were entered and stored on a spread-
sheet (Excel, Microsoft). Mean cortical thickness
and length were used in analyses. Statistical
analysis and visualization were performed using
Matlab (MathWorks). The relationship between
ultrasound measurements and renal function was
tested using linear regression. Significance was
considered at a p value < 0.05.
Results
Details regarding the study population are
given in Table 1. The mean cortical thick-
ness was 5.9 mm (range, 3.2–11.0 mm). The
mean length was 10 cm (range, 7.2–12.4
cm). A statistically significant positive re-
lationship was observed between eGFR and
mean cortical thickness using both the CG
and the MDRD equations (CG, p < 0.0001;
MDRD, p = 0.0050). There also was a statis-
tically significant relationship between CG
eGFR and mean renal length (p = 0.0029)
but not MDRD eGFR (p = 0.0756) (Fig. 2).
The strongest relationship, as evidenced by
the highest r 2 value, was for mean cortical
thickness and CG eGFR (r 2 = 66%).
Discussion
Our series showed a statistically significant
relationship between cortical thickness mea-
sured at ultrasound and renal function in pa-
tients with CKD. Although there was also a
significant relationship between CG eGFR and
renal length, there was not for MDRD eGFR.
Renal length has traditionally been consid-
ered a surrogate marker of renal function be-
cause renal length decreases with decreasing
renal function. Renal lengths are universally
reported and are usually the only measure-
ments given at renal ultrasound [1]. However,
on the basis of our study, it appears that corti-
cal thickness measured at ultrasound may be
related more closely to eGFR than renal length
in patients with chronic renal failure.
W148 AJR:195, August 2010
Beland et al.
100
y = –13.5 + 80.6x, p = 0.0001
r 2 = 0.66
CG
50
0 0
0 0.5 1 1.5
Mean Cortical Thickness (cm)
100
y = 9.1 + 44.7x, p = 0.0050
r 2 = 0.29
MDRD
50
0
0 0.5 1 1.5
Mean Cortical Thickness (cm)
Fig. 2—Graphs show Cockcroft-Gault (CG) (top) and Modification of Diet in Renal Disease (MDRD) study
(bottom) estimated glomerular filtration rate (eGFR) plotted as function of mean cortical thickness (left) and
mean length (right) with best-fit straight line from regression.
As the burden of CKD continues to in-
crease, efforts to reduce the cost of monitor-
ing and managing this disease are needed. Our
study attempted to evaluate the usefulness of
a generally obtainable measurement at ultra-
sound in the setting of CKD as a correlate to
kidney function (eGFR). Prior studies also
have evaluated imaging measurements as sur-
rogate markers of renal function. A study eval-
uating 69 patients with suspected unilateral re-
nal artery stenosis showed renal volume was a
better predictor of single-kidney GFR than re-
nal length. They also showed the addition of re-
nal area and parenchymal thickness measured
at ultrasound to length was a better predictor
of both single-kidney GFR and renal volume
than length measured at ultrasound alone [8].
Another study showed a correlation between
eGFR and renal volumes measured at ultra-
sound in 116 healthy children [13]. Other au-
thors have described kidney volume as a bet-
ter predictor of renal function than renal length
[2, 3]. This was further supported by a study in
2009 by Sanusi et al. [6] showing a weak but
positive correlation between kidney volume
and various indices of GFR, best with mea-
sured creatinine clearance, in 40 patients with
CKD. Their results also showed a significant
correlation with the measured creatinine clear-
100
y = –46.8 + 8.2x, p = 0.0029
r 2 = 0.3
CG
50
6 8 10 12 14
Mean Length (cm)
100
y = –8.7 + 4.5x, p = 0.0756
r 2 = 0.13
MDRD
50
0
6 8 10 12 14
Mean Length (cm)
ance and the CG and MDRD equations, further
validating these estimates of GFR in CKD [6].
Our study is limited by the small study
sample. We hope the results presented here
will serve as a pilot study prompting fur-
ther studies with larger patient samples to
validate the results. Future areas of investi-
gation using larger patient samples may in-
clude development of a predictive range of
renal function given a particular cortical
thickness. Alternatively, a determination of
a threshold cortical thickness above which
renal function is preserved may be identi-
fied. Because of the retrospective design of
our study, measurements were made on the
images after they were obtained. Renal cor-
tex measurements were taken perpendicular
to the renal capsule from the capsule to the
corticomedullary interface. This interface
can be difficult to identify in some patients
in whom there is poor corticomedullary dif-
ferentiation. To ensure accuracy, these mea-
surements ideally would be made prospec-
tively at the time of the examination. This
also would allow real-time image optimiza-
tion to possibly make the corticomedullary
interface more apparent. Additional mea-
surements in the transverse plane or an av-
erage cortical thickness including the upper

and lower poles may prove to be a better rep-
resentation of functioning parenchymal vol-
ume in future studies. Despite these limita-
tions, we found the cortical thickness was
usually easy to measure on the PACS work-
station. The method used in our study also
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likely reflects common practice in which ul-
trasound images are obtained by a technolo-
gist and then interpreted by the radiologist
after the patient has left the department.
Another potential limitation of our study
is the use of computational estimates of re-
nal function, rather than measured GFR. Al-
though both formulas have been previously
validated and are widely used, there is contin-
ued debate over which formula is best [14, 15].
A study by Rule et al. [16] in 2004 showed that
the MDRD equation systematically underes-
timated renal function. The underestimation
was much more pronounced for healthy volun-
teers (29% underestimation) than in patients
with CKD (6.2% underestimation). Howev-
er, their study was performed with a version
of the MDRD equation before standardiza-
tion of creatinine estimates between labora-
tories. The development of the ID–MS-trace-
able MDRD study equation that was used in
our study has allowed the use of standardized
creatinine measurements and should mini-
mize measurement differences [12]. A slight-
ly more recent study directly comparing CG
and MDRD estimates of GFR in patients with
CKD showed the MDRD equation to be more
accurate than the CG equation in patients with
moderate to advanced kidney disease and dia-
betic nephropathy [17]. Our study only evalu-
ated patients with CKD, which would mini-
mize any potential underestimation of GFR
using the MDRD equation relative to patients
without known kidney disease and suggests
MDRD may be the more accurate estimate
applied to our study population [16].
Patients on dialysis were necessarily exclud-
ed from this study. Examining the relationship
between renal function on the basis of serum
creatinine and cortical thickness would be in-
herently flawed in this group because the creati-
nine used for calculation would be a measure of
AJR:195, August 2010 W149
Renal Function in Chronic Kidney Disease
dialysis efficacy rather than native renal func-
tion. Patients without known kidney disease
also were not included in this study. It would
be interesting to see if the correlation between
cortical thickness and eGFR is also identified
in these patients. Although this would be a
more difficult study to perform, evaluating the
applicability of measuring cortical thickness to
healthy kidneys would be valuable.
In summary, we have shown renal cortical
thickness measured at ultrasound appears to
relate to the degree of renal impairment in
patients with CKD, and routine reporting of
cortical thickness should be considered in
such patients who are not on dialysis.
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