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ORIGINAL RESEARCH
Can Renal Sonography Be a Reliable
Diagnostic Tool in the Assessment of
Chronic Kidney Disease?
Gaetano Lucisano, MD, Nicolino Comi, MD, Elena Pelagi, MD, Paola Cianfrone, MD, Laura Fuiano, MD,
Giorgio Fuiano, MD
Article includes CME test
Received March 6, 2014, from the Nephrology
and Dialysis Unit, Magna Graecia University of
Catanzaro, Catanzaro, Italy. Revision requested
April 28, 2014. Revised manuscript accepted for
publication May 16, 2014.
Address correspondence to Gaetano
Lucisano, MD, Nephrology and Dialysis Unit,
Magna Graecia University of Catanzaro, Viale
Europa, 88100 Catanzaro, Italy.
E-mail: gaetano_lucisano@hotmail.com
Abbreviations
ANOVA, analysis of variance; AUC, area
under the curve; CI, confidence interval;
CKD, chronic kidney disease; GFR, glomeru-
lar filtration rate; ROC, receiver operating
characteristic
doi:10.7863/ultra.34.2.299
©2015 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2015; 34:299–306 | 0278-4297 | www.aium.org
Objectives—Kidney size has been found to be correlated with anthropometric features
and kidney function. Therefore, we postulate that if the conventionally measured renal
sonographic parameters (pole-to-pole length, width, and parenchymal thickness) are
taken according to standardized rules and corrected for body height, their association
with kidney function could be strengthened, thus helping validate renal sonographic
information for a better assessment of chronic kidney disease (CKD) status.
Methods—This cross-sectional study included 72 stable adult patients with stage 1 to 4
CKD. Sonographic parameters were obtained from both kidneys and averaged, and the
measurements obtained were further corrected for patients’ body height. The glomerular
filtration rate (GFR) was estimated by the Chronic Kidney Disease Epidemiology
Collaboration equation.
Results—Parenchymal thickness and renal length showed the highest correlation level
with the GFR. This significant correlation, however, was greatly ameliorated by the cor-
rection for patients’ body height (r = 0.537; P < .001; r = 0.510; P < .001, respectively).
Of note, the product of these two parameters corrected for body height showed the best
degree of correlation with the GFR (r = 0.560; P < .001), as confirmed by analysis of
variance after subdivision of the population into CKD stage groups according to the
GFR. Receiver operating characteristic curve analysis for discrimination of a GFR of
less than 60 mL/min indentified the combined parameter as the one with the highest
area under the curve (0.78; 95% confidence interval, 0.66–0.89), followed renal length
corrected for height (area under the curve, 0.77; 95% confidence interval, 0.66–0.88).
Conclusions—Correction of renal sonographic parameters for body height strengthens
the degree of the correlation of renal sonography with the GFR. The improved correlation
with the GFR makes renal sonography a reliable tool for a more complete assessment of
patients with CKD.
Key Words—body height; chronic kidney disease; genitourinary ultrasound; glomerular
filtration rate; kidney length; renal parenchymal thickness; renal sonography
R
enal sonography is an essential diagnostic tool in nephrology.
It represents a first-choice diagnostic procedure for assess-
ment of several kidney and urinary tract diseases because of
its considerable effectiveness in imaging studies of different structures
that constitute the kidney parenchyma. Because of its noninvasive-
ness and low cost, renal sonography is widely used as a diagnostic tool
in daily nephrologic workups, even in bedside settings.1 However, it
is probably underused in the evaluation of renal structural changes
for assessment of chronic renal failure.2
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Lucisano et al—Renal Sonography in Chronic Kidney Disease
In patients with chronic kidney disease (CKD), renal
sonographic dimensional parameters could be of great utility,
providing indirect but valuable information about the mor-
phostructural changes occurring in the kidney in the course
of CKD. Such information could usefully complement the
laboratory investigations commonly performed in the fol-
low-up of the patients with CKD to achieve a more com-
plete assessment of the disease by the combination of
functional and morphostructural information. However, this
possibility is not fully realized yet, probably because the
reliability of renal sonography is questioned by the obser-
vation that sonographic parameters are often operator
dependent, renal dimensions also depend on anthropo-
metric variables,3,4 and that these limitations are not ade-
quately considered in clinical practice. In this study, we tried
to minimize the role of these interfering factors by verify-
ing whether the use of standardized rules for measuring
renal dimensions and appropriate correction of measured
renal sonographic parameters for body height improve the
correlation between sonographic data and the CKD stage
in a cohort of patients with different levels of renal function.
Materials and Methods
Patient Selection
This cross-sectional study included 72 consecutive stable
patients with stage 1 to 4 CKD (26 women) who were
referred to our renal unit between February 1, 2012, and
December 1, 2012. Our study was approved by the Local
Ethical Committee, and all patients gave written informed
consent. Exclusion criteria were the presence of a solitary
kidney, morbid obesity (body mass index ≥40 kg/m2),
diabetes mellitus, liver cirrhosis, renal amyloidosis,
acute kidney injury, rapidly progressive kidney disease,
hydronephrosis, renal transplantation, monolateral or
bilateral cystic kidney disease, renovascular nephropathy,
asymmetry in renal size (defined as a difference of ≥2.0 cm
between left and right kidney lengths), and incipient need
for renal replacement therapy (glomerular filtration rate
[GFR] <15 mL/min and the presence of signs and symp-
toms of severe uremia).
All participants underwent renal sonography. In the
same session, anthropometric data (height and weight,
measured as meters and kilograms, respectively) were
recorded, and a peripheral blood sample was collected to
measure serum creatinine for GFR estimation to stage
CKD by the Chronic Kidney Disease Epidemiology
Collaboration equation.5 We used this equation as cur-
rently suggested by the international guidelines for esti-
mation of the GFR.6 The GFR values were also measured
300
within 7 days after renal scanning to assess the stability of
renal function, and a variation from baseline of 25% or
greater was considered a further exclusion criterion. In all
proteinuric patients, quantitative proteinuria was measured.
Renal Sonographic Examinations
All renal sonographic examinations were performed in the
inpatient setting of our renal unit by the same experienced
investigator with 10 years of experience in the field of renal
sonography, who was blinded to patients’ serum creatinine
values. To reduce the intraobserver variability, each meas-
urement was repeated twice in the same session, and the
average values were taken into account. The examinations
were performed with a 4.0-MHz curvilinear probe and a
LOGIQ C5 Premium ultrasound machine (GE Healthcare,
Zipf, Austria) using standard grayscale B-mode imaging.
The following protocol was followed to perform the meas-
urements: (1) participants underwent renal sonography in
the supine position; (2) kidney length was measured as the
greatest pole-to-pole distance in the sagittal plane; (3) kid-
ney width was measured as the maximum transverse axis in
the hilar region; and (4) kidney parenchymal thickness was
measured as the distance between the sinus fat and the
renal capsule. Kidney parenchymal thickness was obtained
at the upper, middle, and lower poles of both kidneys, and
the average was calculated to avoid any bias due to the vari-
ability of the border between the echogenic sinus fat and
the renal parenchyma (Figure 1). In addition, according to
previous studies,7 we evaluated an unconventional param-
eter derived from the product of mean kidney length and
average kidney parenchymal thickness, corrected for
patients’ body height, for a further estimation of kidney size.
Figure 1. Measured B-mode parameters: maximum kidney pole-to-pole
length (a); maximum kidney width (b); and parenchymal thickness
measured at the upper, middle, and lower poles, respectively (c–e).
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All measurements were performed in both kidneys
and averaged, and the measurements obtained were further
corrected for the patients’ body height by dividing meas-
ured data by the height value. As an example, in a patient
with stage 4 CKD, we obtained the following measure-
ments: right kidney length, 80.1 mm; right kidney width,
42.9 mm; right kidney parenchymal thickness (Figure 1,
e, c, and d), 13.4, 10.1, and 10.3 mm, respectively; left kid-
ney length, 97.7 mm; left kidney width, 53.0 mm; left kidney
parenchymal thickness (Figure 1, e, c, and d), 20.0, 10.9, and
11.1 mm; and body height, 1.6 m. Then the measurements
were averaged: kidney length = (right kidney length + left
kidney length)/2 = (80.1 + 97.7)/2 = 88.9 mm; kidney
width = (right kidney width + left kidney width)/2 = (42.9
+ 53.0)/2 = 47.9 mm; and kidney parenchymal thickness
= [(right e + c + d) + (left e + c + d)]/6 = [(13.4 + 10.1 +
10.3) + (20.0 + 10.9 + 11.1)]/6 = 12.6 mm. Finally,
the data were corrected for body height: corrected kidney
length = 88.9/1.60 = 55.6 mm; corrected kidney width =
47.9/1.60 = 29.9 mm; and corrected kidney parenchymal
thickness = 12.6/1.60 = 7.9 mm.
The interobserver reproducibility of the measure-
ments obtained by the above-mentioned criteria was pre-
liminary tested on a sample of 35 patients with different
CKD stages, and we found a high degree of correlation
between the measurements obtained by two different
investigators, with intraclass correlation coefficients of
0.889 (95% confidence interval [CI], 0.865–0.898), 0.780
(95% CI, 0.750–0.805), and 0.810 (95% CI, 0.780–0.825)
for kidney length, kidney width, and kidney parenchymal
thickness, respectively.
Statistical Analysis
Continuous variables were expressed as mean ± standard
deviation or median (interquartile range) as appropriate.
Comparisons between left and right renal sonographic
parameters were performed by the Student t test, and com-
parisons between sonographic parameters and the GFR
were performed by the Pearson bivariate correlation test.
Then, to assess the variability of the study parameters with
the different degrees of kidney function, the population
was divided into 4 groups according to the international
classification of CKD stages (National Kidney Founda-
tion Kidney Disease Outcomes Quality Initiative8), and B-
mode parameters were compared with the GFR by 1-way
analysis of variance (ANOVA). A post hoc Tukey test was
then applied to analyze the differences between groups.
Finally, receiver operating characteristic (ROC) curves
were drawn, and the areas under the curves (AUCs) were
calculated to investigate the role of sonographic parame-
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Lucisano et al—Renal Sonography in Chronic Kidney Disease
ters for discriminating the presence of a GFR of less than
60 mL/min. Statistical analysis was performed using
PASW Statistics version 18 software (IBM Corporation,
Armonk, NY), and the level of significance was set at
P < .05. Areas under the curves were statistically compared
by the Mann-Whitney test according to the method of
DeLong et al.9
Results
Relationship Between Sonographic Parameters and the
GFR in the Whole Study Cohort
Main characteristics of the study population are shown in
Tables 1 and 2. All participants had normally located kid-
neys, without evidence of duplicated collecting systems,
scars, or parenchymal distortions. There was no significant
difference between right kidney length, kidney width, and
kidney parenchymal thickness compared with the left kid-
ney (P = .445, .132, and .723, respectively). Although the
morphostructural changes occurring in CKD are not nec-
essarily strictly correlated with the GFR, the latter is the
main parameter used in clinical practice for staging CKD.
For this reason, we preliminarily verified the correlation
between renal sonographic dimensions and the GFR,
observing a positive correlation between the GFR and
mean kidney length, kidney width, and average kidney
parenchymal thickness in the whole study cohort (Figure
2). In particular, the B-mode parameters best correlating
with the GFR were kidney parenchymal thickness (r= 0.480;
P < .001) and kidney length (r = 0.460; P < .001), whereas
the worst parameter was kidney width (r = 0.363; P = .02).
After correction for the patients’ body height, such corre-
lations became stronger (Figure 2; kidney parenchymal
thickness, r = 0.537; P < .001; kidney length, r = 0.510;
P < .001) and again better than kidney width (r = 0.371;
P = .001). We also tested the unconventional parameter
derived from the product of mean kidney length and average
kidney parenchymal thickness corrected for the patients’
body height, again finding a high level of correlation with
the GFR (r = 0.560; P < .001).
Relationship Between Sonographic Parameters and
CKD Stages
We grouped the study population according to CKD
stages 1 to 4 (Tables 1–3). We found a significant differ-
ence between CKD groups for kidney length, kidney
parenchymal thickness, and kidney width values, which
were made stronger by correction for the patients’ body
height (Table 3). Kidney parenchymal thickness and kid-
ney length (both corrected and uncorrected measure-
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Lucisano et al—Renal Sonography in Chronic Kidney Disease

ments) were the parameters that varied more significantly
between CKD stage groups (Table 3). When we consid-
ered the unconventional parameter derived from the
product of mean kidney length and kidney parenchymal
thickness corrected for body height, we also found a highly
significant difference between GFR groups (F = 8.36;
P < .001; Table 3).
Receiver Operating Characteristic Curve Analysis
Discriminates the Presence of Stage 3 and 4 CKD
(GFR <60 mL/min) From Stage 1 and 2 CKD
Since only a moderate difference was found regarding sono-
graphic parameters measured in the stage 1 and 2 CKD
groups (GFR ≥60 mL/min), we performed an ROC curve
analysis to identify the best sonographic parameter able to
discriminate a GFR of less than 60 mL/min from a GFR of
60 mL/min or greater (Figure 3). All of the study parame-
ters except for mean kidney width were shown to signifi-
cantly discriminate the presence of stage 3 and 4 CKD, and
the correction for the patients’ body height ameliorated the
AUC value for kidney length and increased the sensitivity
for kidney length and parenchymal thickness (Table 4).
Body height–corrected kidney length was the parameter
with the highest sensitivity, identifying 68.5 mm as the opti-
mal cutoff level with sensitivity of 82.4% and specificity of
75.8% (AUC, 0.77; 95% CI, 0.66–0.88; P < .001). Kidney
parenchymal thickness also had high specificity, identifying
15.0 mm as the optimal cutoff level with sensitivity of 55.9%
and specificity of 92.1% (AUC, 0.74; 95% CI, 0.62–0.86;
P = .001). The combined parameter of kidney length and
kidney parenchymal thickness corrected for body height was
characterized by a cutoff level of 107.0 mm with both high
sensitivity and specificity (70.6% and 84.2%, respectively;
Table 4). After statistical comparison of the ROC curves, we
found a significant difference between kidney length ver-
sus corrected and uncorrected kidney width (P = .01 and
.008), corrected kidney length versus corrected and uncor-
rected kidney width (P = .003 and .01), kidney parenchy-
mal thickness versus corrected and uncorrected kidney
width (P = .019 and .04), corrected kidney parenchymal

Table 1. Demographic Characteristics of the Whole Study Cohort and Divided Into CKD Stage Groups According to GFR

Parameter Total (n = 72) CKD-4 (n = 18) CKD-3 (n = 18) CKD-2 (n = 20) CKD-1 (n = 16)

Female, n 26 8 4 5 9
Age, y 50 ± 17 56 ± 17 60 ± 16 46 ± 16 38 ± 12
Body height, m 1.66 ± 0.08 1.65 ± 0.08 1.66 ± 0.09 1.66 ± 0.07 1.66 ± 0.08
Body mass index, kg/m2 26.3 ± 4.4 26.3 ± 4.2 27.9 ± 4.8 26.5 ± 4.4 24.3 ± 3.8
Serum creatinine, mg/dL 1.5 ± 0.9 2.8 ± 0.9 1.4 ± 0.2 1.0 ± 0.1 0.7 ± 0.1
GFR, mL/min 63.5 ± 35.0 22.8 ± 7.1 48.8 ± 7.2 74.1 ± 8.8 112.4 ± 25.0
Systolic blood pressure, mm Hg 130 ± 19 135 ± 19 137 ± 19 121 ± 18 128 ± 16
Diastolic blood pressure, mm Hg 78 ± 12 78 ± 16 81 ± 9 76 ± 11 78 ± 12
Hemoglobin, g/dL 12.9 ± 1.9 11.3 ± 1.7 13.2 ± 1.9 13.6 ± 1.6 13.3 ± 1.3
Fasting blood glucose, mg/dL 90 ± 11 86 ± 9 97 ± 10 90 ± 10 86 ± 12
Total cholesterol, mg/dL 195 (174–218) 175 (148–210) 175 (161–209) 196 (185–241) 212 (192–224)
HDL cholesterol, mg/dL 50 (42–62) 51 (38–65) 47 (40–51) 45 (44–62) 60 (54–69)
Plasma calcium, mg/dL 9.4 ± 0.6 9.4 ± 0.7 9.3 ± 0.7 9.3 ± 0.5 9.5 ± 0.5
Serum phosphorus, mg/dL 3.5 (3.1–4.1) 4.0 (3.5–4.2) 3.7 (3.2–4.1) 3.3 (3.0–3.7) 3.4 (3.0–4.0)
Proteinuria, g/24 h 0.9 (0.3–2.0) 2.0 (1.4–4.5) 1.4 (0.3–2.0) 0.6 (0.3–1.2) 0.3 (0.2–0.4)
Data are presented as mean ± SD and median (interquartile range) where applicable. Glomerular filtration rates estimated by the Chronic Kidney
Disease Epidemiology Collaboration equation: CKD-4 group, 15 to 29 mL/min; CKD-3 group, 30 to 59 mL/min; CKD-2 group, 60 to 89 mL/min;
and CKD-1 group, 90 mL/min or higher. HDL indicates high-density lipoprotein.

Table 2. Sonographic Characteristics of the Whole Study Cohort and Divided Into CKD Stage Groups According to GFR

Parameter Total (n = 72) CKD-4 (n = 18) CKD-3 (n = 18) CKD-2 (n = 20) CKD-1 (n = 16)

Right kidney length, mm 111 ± 13 104 ± 17 106 ± 12 116 ± 10 115 ± 10

Right kidney width, mm 50 ± 7 47 ± 10 51 ± 6 51 ± 7 51 ± 5
Right kidney parenchymal thickness, mm 16 ± 3 14 ± 3 16 ± 3 16 ± 2 19 ± 2
Left kidney length, mm 111 ± 12 106 ± 13 106 ± 12 117 ± 9 117 ± 11
Left kidney width, mm 51 ± 8 47 ± 8 51 ± 8 52 ± 6 55 ± 8
Left kidney parenchymal thickness, mm 16 ± 3 15 ± 3 15 ± 3 17 ± 3 19 ± 3
Data are presented as mean ± SD. Glomerular filtration rate estimates are as in Table 1.

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Lucisano et al—Renal Sonography in Chronic Kidney Disease

thickness versus corrected and uncorrected kidney width (P Discussion

= .01 and .04), and the unconventional parameter versus
corrected and uncorrected kidney width (P = .002 and .005).
Nearly significant was the comparison between the uncon-
ventional parameter and corrected and uncorrected kidney
parenchymal thickness (P = .07 and .08). All other paired
curve comparisons were shown to be not significant.
In our cohort of stable patients with CKD, we found that
correction of the conventional B-mode sonographic renal
parameters (pole-to-pole length, width, and parenchymal
thickness) for body height and the adoption of standardized
criteria for measuring renal dimensions significantly

Figure 2. Bivariate correlation between estimated GFR (eGFR) and mean kidney pole-to-pole length (A), mean kidney width (B), and average
parenchymal thickness (C). Crude indicates uncorrected measurements. For each measurement, the Pearson correlation coefficient and the sig-
nificance level are shown.
A B C

Table 3. Analysis of Variance and Tukey Post Hoc Test of the Investigated B-Mode Sonographic Parameters According to CKD Stage Groups

Parameter ANOVA CKD-4 CKD-3 CKD-2

Renal length F = 6.14 .992a

P = .001 .007b .017b
.021c .043c .998c
Renal length corrected for body height F = 6.96 997a
P < .001 .005b .009b
.012c .022c .999c
Renal width F = 2.96 .234a
P = .038 .129b .994b
.032c .774c .885c
Renal width corrected for body height F = 3.01 .246a
P = .036 .141b .995b
.028c .725c .838c
Renal parenchymal thickness F = 8.02 .809a
P < .001 .130b .568b
<.001c .002c .054c
Renal parenchymal thickness corrected for body height F = 8.06 .849a
P < .001 .170b .599b
<.001c .002c .040c
Renal length × parenchymal thickness F = 8.36 .919a
corrected for body height P < .001 .034b .153b
<.001c .001c .239c
Glomerular filtration rate estimates are as in Table 1.
aP versus CKD-3 group; bP versus CKD-2 group; cP versus CKD-1 group.

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Lucisano et al—Renal Sonography in Chronic Kidney Disease
Figure 3. Receiver operating characteristic curves of the conventional
B-mode renal sonographic parameters (both uncorrected and corrected
for body height) and the unconventional parameter obtained by the
combination of kidney length and renal parenchymal thickness.
improved the usefulness of sonographic information in CKD.
Renal sonography is an undervalued tool in the assessment
of patients with chronic renal impairment, whose pro-
gression is usually staged only according to GFR levels.
However, it is well known that GFR levels can be notably
influenced by several functional and pharmacologic
factors that alter systemic or renal hemodynamics and,
consequently, cannot accurately reflect the extent of renal
disease in all clinical situations.10 For example, the GFR
can be normal even in patients with severe tubular dam-
age11; on the other hand, many clinical circumstances and
drugs (eg, diuretics and renin-angiotensin blockers) can
determine transient or persistent reductions in the GFR
Table 4. Receiver Operating Characteristic Curve (GFR <60 mL/min) Analysis Data
Parameter Cutoff Value, mm
Renal length 111.5
Renal length corrected for height 68.5
Renal width 48.7
Renal width corrected for height 25.8
Renal parenchymal thickness 15.0
Renal parenchymal thickness
corrected for height 9.3
Renal length × parenchymal thickness
corrected for height 107.0
304
even in the absence of substantial renal morphostructural
changes. Therefore, in the evaluation of patients with
CKD, it is very important for the clinician to know whether
modifications in renal function are paralleled by mor-
phostructural changes. Currently, renal sonography rep-
resents the only procedure that can be safely repeated in
patients with CKD and can provide indirect but reliable
information of the kidney structure, as also suggested by
studies that have analyzed the correlation between sono-
graphic measurements and histologic and functional
parameters. In fact, a retrospective study on patients
undergoing renal biopsy showed a significant correlation
between kidney length and the prevalence of global scle-
rosis and focal tubular atrophy.12 Such findings have been
more recently confirmed in a study in which the sono-
graphically measured renal size was found to be inversely
correlated with the extent of glomerular sclerosis and
tubular atrophy.13 On the other hand, the clinical utility
of renal sonography in CKD is often questioned, mainly
because the procedure is dependent on operator skill, and
renal dimensions are highly dependent on the anthropo-
metric characteristics of the patients. In this study, we tried
to mitigate these limitations by improving the repro-
ducibility of the procedure and reducing the body size–
dependent variability of the measurements. The increased
reproducibility was obtained by following clear criteria to
measure the renal dimensions, which was successfully ver-
ified by a very high interobserver reproducibility score
obtained in a preliminary test.
In previous studies, the correlation between renal
dimensions and functional data was already evaluated in
relation to different GFR levels, and even in these studies
kidney length was found to be useful for discriminating
acute from chronic kidney disease.14,15 Also, in our cohort,
uncorrected kidney length was positively correlated with
the GFR,16,17 but we found that the correction of this
parameter for patient body height sensibly also ameliorated
the correlation (Figure 2A) after the subdivision of the
AUC (95% CI) Sensitivity, % Specificity, % P
0.75 (0.64–0.87) 70.6 76.3 <.001
0.77 (0.66–0.88) 82.4 75.8 <.001
0.63 (0.49–0.76) 55.9 76.3 .065
0.60 (0.47–0.73) 23.5 100 .159
0.74 (0.62–0.86) 55.9 92.1 .001
0.73 (0.61–0.85) 58.8 86.8 .001
0.78 (0.66–0.89) 70.6 84.2 <.001
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cohort into groups with different CKD stages (Table 3).
Analysis of variance and the post hoc test revealed that the
most significant differences between uncorrected kidney
length and kidney length corrected for body height were
observed in the GFR range of 30 to 90 mL/min (Table 3),
confirming that the more substantial structural changes
in the kidney occur in stages 2 and 3 of CKD. Of note,
analysis of ROC curves for the prediction of a GFR of less
than 60 mL/min confirmed that kidney length was the
measured B-mode parameter with the highest AUC and
the best sensitivity and specificity, and the correction for
body height further ameliorated the AUC and sensitivity
(Figure 3 and Table 4).
Kidney parenchymal thickness was also found to be
a very reliable parameter. We deliberately preferred to
measure kidney parenchymal thickness instead of cortical
thickness because in patients with poor corticomedullary
differentiation, such as those with moderate to advanced
CKD, the corticomedullary interface is hard to identify,18
and the reproducibility is low.19 Moreover, parenchymal
but not cortical thickness has been inversely associated
with the extent of tubular atrophy.13 In our cohort of
patients with CKD, kidney parenchymal thickness showed
a very high degree of correlation with the GFR (Figure 2C),
and also in this case, the correction for patient body height
was statistically ameliorative. Analysis of variance and post
hoc analysis confirmed such an observation, showing sig-
nificant differences between GFR groups and highlighting
that body height–corrected kidney parenchymal thickness
was the only parameter that was progressively reduced in
parallel with the GFR (Table 3). In fact, the ROC analysis
showed kidney parenchymal thickness to have the highest
specificity among all of the study parameters but an inferior
AUC compared with renal length (Figure 3 and Table 4).
Kidney width was the parameter with the worst correla-
tion, even when corrected for height, so we suggest that it
should not be considered in evaluations of kidneys with
chronic insufficiency, as also reported in previous studies.15
A fourth parameter was finally calculated and evalu-
ated in our study. In fact, starting from the results of our
bivariate correlation between the measured sonographic
parameters and GFR (Figure 2), we presumed that the
product of the two parameters with the best correlation
with the GFR, namely, mean kidney length and average
kidney parenchymal thickness, corrected for the patients’
body height, could show an even higher correlation with
the GFR. Indeed, ANOVA of this calculated parameter
showed the highest significant difference between GFR
groups (Table 3), and the parameter also showed speci-
ficity and sensitivity for discrimination between CKD
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Lucisano et al—Renal Sonography in Chronic Kidney Disease
stages (Figure 3 and Table 4). We did not calculate sono-
graphically estimated renal volume because the ellipsoid
formula underestimates renal volume by 17% to 29%,18,20,21
and the interobserver variation for renal volume is far
too high.19
In conclusion, kidney length could be considered the
best parameter to use for estimating renal size19,22,23 and,
indirectly, the structural modifications occurring in stable
CKD because of the significant positive correlation with
the GFR and the significant difference between different
CKD stages, particularly when a correction for body height
is applied. We believe that an important strength of this
study was the population selection: we excluded patients
characterized by clinical features that could have poten-
tially influenced the sonographic investigation and thus
could have compromised correct collection or caused an
overestimation or underestimation of the sonographic
parameters. Also, we repeated the serum creatinine meas-
urement within 7 days after the sonographic investigation
to ascertain the stability of kidney function. Finally, we
adopted clear and uniform measurement criteria, obtaining
high measurement reproducibility, and normalized the
results for body height.
A major limitation of this study was the lack of longi-
tudinal data, which would better account for the changes
in renal sonographic parameters compared to the modifi-
cations in the GFR during the progression of CKD.
Nonetheless, our main purpose was to verify whether
standardizing the measurement methods and normalizing
the dimensional parameters for body height can help pro-
vide reliable renal sonographic structural data for improv-
ing the assessment of stable CKD. Another limitation of
our study was the small sample sizes for CKD stage com-
parisons. However, our ANOVA results are in line with
those of bivariate correlation. An additional potential lim-
itation was that measurements were performed during the
same session, which may have introduced a bias, although
this process could reflect what is usually done in routine
clinical practice.
Our data suggest that renal length and parenchymal
thickness corrected for the patients’ body height are repro-
ducible and useful renal sonographic parameters for bet-
ter assessment of stable CKD, in addition to clinical and
functional data. However, renal length normalized for
body height is also the measured parameter that best
discriminates the presence of a moderately reduced GFR
and should be preferred in clinical practice. Other uncon-
ventional parameters, such as the product of renal length
and parenchymal thickness corrected for height, appear
promising but need further validation.
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Lucisano et al—Renal Sonography in Chronic Kidney Disease

References 18. Beland MD, Walle NL, Machan JT, Cronan JJ. Renal cortical thickness
measured at ultrasound: is it better than renal length as an indicator of
1. Spyridopoulos TN, Kaziani K, Balanika AP, et al. Ultrasound as a first line renal function in chronic kidney disease? AJR Am J Roentgenol 2010;
screening tool for the detection of renal artery stenosis: a comprehensive 195:W146–W149.
review. Med Ultrason 2010; 12:228–232. 19. Emamian SA, Nielsen MB, Pedersen JF. Intraobserver and interobserver
2. Buturovic-Ponikvar J, Visnar-Perovic A. Ultrasonography in chronic renal variations in sonographic measurements of kidney size in adult volun-
failure. Eur J Radiol 2003; 46:115–122. teers: a comparison of linear measurements and volumetric estimates.
3. Raza M, Hameed A, Khan MI. Ultrasonographic assessment of renal size Acta Radiol 1995; 36:399–401.
and its correlation with body mass index in adults without known renal 20. Bakker J, Olree M, Kaatee R, et al. Renal volume measurements: accuracy
disease. J Ayub Med Coll Abbottabad 2011; 23:64–68. and repeatability of US compared with that of MR imaging. Radiology
4. Pruijm M, Ponte B, Ackermann D, et al. Heritability, determinants and 1999; 211:623–628.
reference values of renal length: a family-based population study. Eur 21. Cheong B, Muthupillai R, Rubin MF, Flamm SD. Normal values for renal
Radiol 2013; 23:2899–2905. length and volume as measured by magnetic resonance imaging. Clin J
5. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate Am Soc Nephrol 2007; 2:38–45.
glomerular filtration rate. Ann Intern Med 2009; 150:604–612. 22. Widjaja E. Ultrasound measured renal length versus low dose CT vol-
6. Stevens LA, Schmid CH, Greene T, et al. Comparative performance of the ume in predicting single kidney glomerular filtration rate. Br J Radiol 2004;
CKD Epidemiology Collaboration (CKD-EPI) and the Modification of 77:759–764.
Diet in Renal Disease (MDRD) study equations for estimating GFR lev- 23. Van Den Noortgate N, Velghe A, Petrovic M, et al. The role of ultra-
els above 60 mL/min/1.73 m2. Am J Kidney Dis 2010; 56:486–495. sonography in the assessment of renal function in the elderly. J Nephrol
7. Buchholz NP, Abbas F, Biyabani SR, et al. Ultrasonographic renal size in 2003; 16:658–662.
individuals without known renal disease. J Pak Med Assoc 2000; 50:12–16.
8. National Kidney Foundation. K/DOQI clinical practice guidelines for
chronic kidney disease: evaluation, classification, and stratification. Am J
Kidney Dis 2002; 39(suppl 1):S1–266.
9. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas
under two or more correlated receiver operating characteristic curves: a
nonparametric approach. Biometrics 1988; 44:837–845.
10. Parrish AE, Rubenstein NH, Howe JS. Correlation between renal function
and histology. Am J Med Sci 1955; 229:632–637.
11. Risdon RA, Sloper JC, De Wardener HE. Relationship between renal
function and histological changes found in renal-biopsy specimens from
patients with persistent glomerular nephritis. Lancet 1968; 2:363–366.
12. Hricak H, Cruz C, Romanski R, et al. Renal parenchymal disease: sono-
graphic-histologic correlation. Radiology 1982; 144:141–147.
13. Moghazi S, Jones E, Schroepple J, et al. Correlation of renal histopathol-
ogy with sonographic findings. Kidney Int 2005; 67:1515–1520.
14. Ozmen CA, Akin D, Bilek SU, Bayrak AH, Senturk S, Nazaroglu H.
Ultrasound as a diagnostic tool to differentiate acute from chronic renal
failure. Clin Nephrol 2010; 74:46–52.
15. Paleologo G, Abdelkawy H, Barsotti M, et al. Kidney dimensions at sonog-
raphy are correlated with glomerular filtration rate in renal transplant recip-
ients and in kidney donors. Transplant Proc 2007; 39:1779–1781.
16. Sanusi AA, Arogundade FA, Famurewa OC, et al. Relationship of ultra-
sonographically determined kidney volume with measured GFR, calcu-
lated creatinine clearance and other parameters in chronic kidney disease
(CKD). Nephrol Dial Transplant 2009; 24:1690–1694.
17. Donadio C, Abdelkawy H, Grassi G. Echographic renal dimensions can
predict glomerular filtration rate of potential living kidney donors. Transplant
Proc 2010; 42:1035–1039.

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