RENOVASCULAR DISEASE index (RI) is 0.70 or less and varies with the heart rate.

13
Renovascular disease (renal artery
stenosis/obstruction or renal vein occlusion) can lead to
renal failure. Spectral and color Doppler can effectively
evaluate the renal vasculature (Fig. 21).101 Normal flow in
the renal arteries is of low peripheral resistance with
significant forward flow in diastole. The normal resistive
Rather than using a single measurement, av- eraging a
number of measurements may be more appropriate.12 The
majority of cases of bilateral renal artery stenosis (RAS)
leading to renal insufficiency are due to atherosclerotic
vessel disease. Most of these stenoses involve the proximal
renal artery just at or beyond its origin from the abdominal
aorta.

FIGURE 15. Retroperitoneal

fibrosis. A, Transverse and (B)
longitudinal sonograms
demonstrating a mantle of
hyperechoic tissues surrounding
the aorta (AO) to both sides of
midline (arrows). Spine (S). Gall-
bladder (G).

TABLE 4. Mimics of Hydronephrosis
Overhydration
Overdistended bladder
Prominent blood vessels in the renal sinus
Pregnancy
Parapelvic cyst(s)
Papillary necrosis
Chronic pyelonephritis
Reflux nephropathy
Congenital megacalices, megaureter
Diabetes insipidus
Doppler ultrasound will detect abnormal velocities at or just
distal to the stenosis; however, this portion of the renal artery
is not visible in most patients. 102 Another approach has been
to look for the presence of a tardus-parvus waveform
including a prolonged acceleration time, diminished
acceleration index, and loss of the normal early systolic
compliance peak/re- flective-wave complex (ESP) in the
downstream renal arteries of the kidneys. 103 The poststenotic
pulsus tardus is due to the compliance of the poststenotic
vessel wall in conjunction with the stenosis, which produces
the tardus effect by dampening the high-frequency
components of the arterial waveform.104 Kliewer et al105
discovered that there was good interobserver agreement in
the interpretation of the morphology of these waveforms.
Stavros et al103 found that absence of the ESP was the best
parameter to use. It had a sensitivity of 95%, specificity of
97%, positive predictive value of 92%, and negative
predictive value of 98% and an overall accuracy of 96%.
Postma et al,106 in a study of 60 patients, 24 with renal artery
stenosis, found a sensitivity of 62.5%, a specificity of 86.4%,
and an overall accuracy of 73.9% in diagnosing RAS. The
study could not be performed in 15 patients (24.5%).
Kliewer et al, in a study of 46 patients with hypertension did
not find it helpful in detecting RAS. 105,107 Other authors have
used varied Doppler waveform parameters with varying
degrees of success in diagnosing RAS including the RI and
comparing it to the opposite kidney (delta RI) and the renal-
aortic ratio.108–112 The delta RI can be misleading if there is
bilateral RAS.111 Ultrasound is more successful in making the
diagnosis of RAS when it is severe.108,110,111 The success rate
of
FIGURE 16. Renal sinus
vasculature mimicking
hydronephrosis. A, Lon- gitudinal
sonogram of the kidney showing
the examination can be improved with the use of ultrasound
contrast agents. Dowling et al 113 had a success rate of 91% in
diagnosing RAS using Levovist. As a screening tool for
RAS, ultrasound is most successful when used in patients in
whom the index of suspicion is high. 108 Owing to the
difficulty in making this diagnosis in some patients, other
imaging techniques are used, including magnetic resonance
angiography (MRA) and CTangiography (CTA) if renal
function permits the use of intravenous iodinated contrast.
Spectral Doppler is a useful tool in determining the success
of percutaneous stenting for treating RAS and in monitoring
their long-term follow- up.114,115
Acute renal failure can result from bilateral occlusion
of the renal arteries or veins. This may be associated with
anuria. Spectral and color Doppler are effective in
diagnosing occlusion of the renal arteries. Renal artery
occlusion may be secondary to emboli from the heart,
atherosclerotic ulcers, or aortic dissection (Fig. 22). In acute
obstruction of the renal arteries the kidneys appear
sonographically normal on grayscale ultrasound, while
spectral and color Doppler will demonstrate absence of
blood flow in the kidneys (Fig. 23). If the process is not
reversed, the kidneys will shrink over time. When segmental
areas of infarction are present, these can appear as wedge-
shaped echogenic masses with absent blood flow.116 Acute
renal vein thrombosis in the absence of a tumor can result
from membranous glomerulonephritis and de- hydration. In
the acute phase, the kidney becomes enlarged and
hypoechoic and the corticomedullary junction disap-
pears.117 The thrombus in the vein is usually anechoic and not
visible without using spectral and color Doppler. In the
chronic stage of renal vein obstruction there is increased
cortical echogenicity, loss of the corticomedullary
junction, and a decrease in renal size. 117 The renal arteries
show absence or reversal of end diastolic flow; however, this
is a variable finding and is neither sensitive nor specific (Fig.
24).118 A normal arterial waveform can be found in the
presence of a venous thrombus.118
AUTOSOMAL DOMINANT POLYCYSTIC
KIDNEY DISEASE
Autosomal dominant polycystic kidney disease
(ADPKD) is sonographically evident when there are
multiple bilateral renal cysts varying in size from millimeters
to many
what appears to be a slightly
distended pelvis (P) with some
calyceal distension (arrows). B, The
color flow Doppler image shows
that the hypoechoic structures in
the renal sinus represent renal
arteries and veins.
FIGURE 17. Parapelvic cysts.
Longi- tudinal sonograms of the (A)
right and (B) left kidneys showing
multiple parapelvic cysts in the
sinuses of both kidneys. C and D,
This finding was confirmed on a
delayed con- trast-enhanced CT
scan.

papillary necrosis. There is blunting of the calyces (C) due to

loss of papillary tissue (arrows).

FIGURE 18. Papillary necrosis. Longitudinal sonogram of the

kidney in a patient with sickle cell disease with evidence of
centimeters (Fig. 25). Ultrasound plays a role in screening
and treating patients with ADPKD. 119 The kidneys get larger
over time due to an increase in the size and number of the
cysts (Fig. 26).120 Patients usually present in the fourth and
fifth decades of life with hypertension, hematuria, urinary
tract infection, and/or palpable flank masses. Only half of
these patients will have a family history of the disease due
to its variable penetrance. It leads to renal failure in 50% of
patients, usually by 60 years of age.121 Patients with
ADPKD make up approximately 5% of patients on dialysis.
ADPKD is the fourth leading cause of patients entering end
stage renal disease programs. Other associated findings
include cysts of the liver (60%), spleen (5%), and pancreas
(10%), and cerebral berry aneurysms. Complications of the
renal cysts include hemor- rhage, infection, and rupture.
Sonographically, the presence of hemorrhage or
superimposed infection is suggested by the presence of a
thickened wall, echogenic debris, or a fluid-fluid level
within the cyst(s). Focal echogenic areas with acoustic
shadowing may occur because of both dystrophic
calcifications within the wall of the cysts and the presence
of stones.122 The number of renal stones in the kidney relates
to the number and size of the renal cysts that cause urinary
obstruction and stasis.122
Acquired cystic kidney disease (ACKD) occurs in up
to 90% of patients who have been on dialysis for 5 years or
longer. Cysts can be found in end stage renal disease before
dialysis is started and in patients on peritoneal dialysis.123–125
The cysts that occur in the cortex and medulla are usually
small (,1 to 3 cm) and do not cause enlargement of
the kidneys (Fig. 27). They may undergo hemorrhage.
Renal cell carcinoma can occur in 4% to 10% of patients. 124–
127
Because of the increased risk, ACKD patients should be
followed
FIGURE 19. Diabetes insipidus.
Lon- gitudinal sonogram of the (A)
right kidney demonstrates marked
hydro- nephrosis (H). B, A pelvic
sonogram shows hydroureter (U)
down to the level of the bladder (Bl),
which is markedly distended.

Hepatorenal syndrome Renal

closely for the development of renal cell carcinoma. 123,125 In tuberculosis Sarcoidosis
a study by Takase et al,126 contrast-enhanced sonography
demonstrated enhancement in 12 of 13 patients with renal Dysproteinemia—myeloma, amyloidosis
cell carcinoma. Taylor et al,127 in a prospective study of 41 Hereditary—oxalosis, renal tubular acidosis
patients comparing contrast-enhanced CT and ultrasound,
found both modalities correctly identified three tumors.
However, CT (59%) was better than ultrasound (18%) in
detecting cysts. Initially, the kidneys decrease in size during
the first 3 years of dialysis, after which they become
enlarged as the number of cysts increase. The kidneys can
progress to have an appearance similar to ADPKD (Fig.
28).128,129

ULTRASOUND-GUIDED RENAL BIOPSIES

A percutaneous biopsy must be performed if a specific
histological diagnosis of parenchymal renal disease is
needed. Biopsy is usually done using ultrasound guidance.130
Ultrasound guidance facilitates a quick and well-tolerated
procedure as the biopsy needle can be seen in real time.131–133
CT-guided biopsy can be performed if the kidneys cannot be
adequately visualized by sonography. Alternatively, a trans-
jugular renal biopsy can be substituted in difficult patients.134
The patient’s coagulation parameters must be checked
before biopsy is performed. These tests include complete
blood count (CBC), protime (PT), and partial thromboplastin
time (PTT); some recommend performing a bleeding time.135

TABLE 5. Chronic Renal Insufficiency

Diabetic nephropathy
Hypertensive nephropathy
Chronic glomerulonephritis

Autosomal dominant polycystic kidney disease

Chronic pyelonephritis

Renovascular disease Metabolic

—gout, hypercalcemia
Nephrotoxins

Any medication that increases the risk of bleeding must be
stopped (eg, heparin or coumadin). Aspirin and
nonsteroidal anti-inflammatory drugs (NSAID) should not
be taken for 5 days prior to the biopsy. Uremic
coagulopathy can be treated with Deamino D Arginine
Vasopressin (DDAVP), estrogen, or transfusion of
cryoprecipitate.135 The patient’s blood pressure should be
checked to make sure it is under control. Prior to the
biopsy, informed written consent is obtained. The risks
(bleeding and infection) and benefits (specific diagnosis
that is amenable to treatment) and alternatives, if any of
the procedure must be explained to the patient.
The ultrasound-guided biopsy can be performed with
the patient in the prone position with a pillow underneath
the abdomen if needed.130 A subcostal approach is used,
but if the kidney cannot be reached in this fashion the
intercostal route can be used. In large obese patients, neither
of these approaches may work. In such cases the upside
kidney can be biopsied with the patient in the decubitus
position, by going through the flank posterior to the colon. In
this position the kidney moves inferiorly and anteriorly and
provides a subcostal access site for biopsy. Once the skin
entry site is selected, it is
FIGURE 20. Chronic renal failure secondary to diabetic
nephropathy. The renal parenchymal echogenicity is ap-
proaching that of the renal sinus fat. A small benign cyst
(arrows) is present in the mid to lower portion of the left
kidney.
FIGURE 21. Normal spectral and
color flow Doppler imaging of the
kidneys demonstrating flow within
the (A) renal artery and (B) renal
vein. The normal resistive index
ranges from 0.56 to 0.70.

FIGURE 22. Embolism to the renal

artery. A, Normal sonogram of the
left kidney. Color Doppler flow
showed no evidence of flow in the
kidney. B, A contrast-enhanced CT
scan shows thrombus within the left
renal artery (arrows).

FIGURE 23. Acute renal failure secondary to traumatic bilateral renal artery occlusion secondary to intimal injury. The (A) right
and
(B) left kidneys appear sonographically normal; however, color Doppler imaging failed to demonstrate blood flow in either
kidney. C, Contrast-enhanced CT scan of the kidneys reveals global infarction of the right kidney with almost total lack of
perfusion of the left kidney secondary to bilateral renal artery intimal damage (arrow).
FIGURE 24. Thrombosis of the left renal vein. Longitudinal scan of (A) diffusely enlarged globular-shaped 5.1-cm-long left
kidney. There is some loss of definition of the corticomedullary junction compared with the normal right kidney. B, CFD imaging
of the left renal sinus demonstrates spectral Doppler of the renal artery with reversal of flow in diastole (arrows). C, Transverse
scan of the left renal vein containing thrombus (arrows) as it crosses in front of the aorta (Ao).

FIGURE 25. Early autosomal domi-

nant polycystic kidney disease. A
and B, Cysts of various sizes are
seen in both kidneys (arrows);
however, the kidneys are not
enlarged.

FIGURE 26. Autosomal dominant

polycystic kidney disease.
Longitudi- nal sonogram of the (A)
left kidney demonstrates
enlargement of the kidney, which
contains multiple cysts of various
sizes. B, Noncontrast CT scan
demonstrates multiple renal and
hepatic cysts (arrows) and two tiny
punctate calcifications in the left
kidney.
FIGURE 27. Acquired cystic kidney
disease. Multiple small cysts are
identified in (A) left kidney consis-
tent with acquired cystic kidney
disease in this patient who has
been on dialysis for almost 7 years.
B, Noncontrast CT scan shows the
cysts in both kidneys (arrows).

cleaned with Betadine and appropriately draped with sterile
towels. A liberal amount of local anesthesia is administered
down to the level of the kidney. In large patients, this can be
done using ultrasound guidance. After making a small
incision in the skin, three biopsies are performed using a
needle guide and an 18-gauge cutting needle. Either kidney
can be biopsied using this technique; the choice should be
based on accessibility. The biopsies are done in suspended
inspiration, targeting the cortex of the lower pole of the kidney.
The specimens are given to the pathologist on non-stick Telfa
pads moistened with sterile non-bacteristatic saline. The
number of specimens obtained varies with the practitioner; we
routinely obtain three specimens.
A repeat ultrasound of the kidney following the biopsy
to detect possible complications is usually not indicated or
helpful.131 The patient should be kept on complete bed rest
for a number of hours following the procedure and the pulse
and blood pressure should be monitored.
Diagnostic tissue can be obtained in a little over 98%
of patients.131,132 The risk of minor bleeding is around 2% to
3% and is slightly greater in women than in men while the
risk of significant bleeding that requires blood transfusions
or intervention is less than 1%.132,133,136,137 Small arteriovenous
fistulas (9%) may occur but these are usually not clinically
significant and resolve spontaneously.
FIGURE
28.
Acquired
cystic
kidney
disease
looking
like
autosoma
l
dominant
polycystic
kidney
disease.
A and B,
Longitudi
nal
sonogram
s of both
kidneys
demonstr
ating nor-
mal-
appearing
kidneys in
a patient
with
recent
onset of
renal
failure. B
and C,
After 8
years of
renal
dialysis
the
kidneys
are
enlarged
and con-
tain
numerous
cysts
mimicking
auto-
somal
dominant
polycystic
kidney
disease.