IMAGING AND BIOPSY

Renal imaging Intravenous urography (IVU)

Arun Sebastian
Paul Tait
Abstract
The renal tract is investigated mainly to identify the underlying cause in
patients with abnormal renal function, renal colic or haematuria.
Increasing use of ultrasound and computed tomography has limited the
role of plain radiographs, but these are still used in the initial
assessment of abdominal colic to evaluate potential renal or bowel
abnormalities. Intravenous urography e radiological examination of the
urinary tract per-
formed following the intravenous injection of iodinated contrast e is
the
classical means by which to assess the kidneys and ureters. Ultrasound
is often the first imaging modality used to interrogate and follow up
renal abnormalities. Computed tomography (CT) can be useful to
evaluate renal masses and determine the site of ureteric obstruction by
calculi. Magnetic resonance imaging (MRI) is primarily used to assess
the renal arteries in patients with suspected renal artery stenosis. CT
and MRI can provide images of exceptional detail and resolution
beyond the means of other modalities, and are thus often used to
characterize and follow renal masses; in addition, images can be
obtained in multiple planes. Radionuclide scans can be helpful in the
evaluation of renal tract obstruction and provide a functional
assessment of the renal tract.
IVU is performed following intravenous injection of iodinated
contrast medium and serial radiographs are taken to follow the
progress of contrast within the urinary tract. The initial neph-
rographic phase (when the contrast is in the renal parenchyma)
confirms the glomeruli are filtering blood (and hence excreting
contrast). This phase may help to confirm the intrarenal location
of a calculus projected over the renal outline on the KUB. Focal
lesions, such as cysts and tumours in the renal parenchyma, may
be apparent during this phase. The subsequent urographic phase
will identify calculi or urothelial tumours in the renal pelvis and
ureters, and help in the assessment of urinary obstruction. The
delay in passage of contrast into the renal pelvis and ureter
(persistent nephrographic phase), if unilateral, is a sign of
obstruction; bilateral delay implies a systemic cause, such as
poor kidney perfusion or function. IVU will also aid in the
detection of congenital abnormalities of the urinary system, such
as horseshoe kidney, ureteric duplication and ureteroceles. IVU
is contraindicated in patients with contrast allergy and in
pregnant women. Adequate visualization of the renal pelvicaly-
ceal system and upper ureters often requires abdominal
compression during the IVU examination and this is contra-
indicated in patients with abdominal pain and abdominal aortic
aneurysms.
Advantages: IVU can help to distinguish a collecting system
dilated because of current obstruction from one showing
residual dilatation as a result of previous obstruction.

Keywords computed tomography; KUB; magnetic resonance imaging;

renal angiogram; renal biopsy; renal imaging
Disadvantages: IVU requires intravenous contrast administra-
tion and the radiation dose is 2.5 times that of a chest
radiograph. It may not be possible to delineate the specific
nature of a space-
Indications Paul Tait MA FRCR is Consultant Interventional Radiologist at Hammer-
smith Hospital, London, UK. Competing interests: none declared.
Abnormal renal function is the most common indication for
renal imaging. Other indications include renal colic, haematuria
and the investigation of hypertension where a renal vascular
cause is suspected (renal artery stenosis).

Plain abdominal radiographs

The increasing use of ultrasound and computed tomography
(CT) has limited the use of plain radiographs, but they still have
a role in the management of the acute abdomen. The kidney-
ureter-bladder (KUB) radiograph may demonstrate urinary
stones. However, approximately 10% of urinary stones are
undetectable by plain radiography because they are not radio-
opaque, and those stones that are detectable may be obscured
by bowel gas. In the pelvis, phleboliths (calcified venous throm-
bosis) may be mistaken for ureteric stones. Phleboliths typically
have a relatively radiolucent centre, which helps to differentiate
them from urinary stones.

Arun Sebastian MRCP FRCR is a Consultant Radiologist at the Colchester

General Hospital, UK. Competing interests: none declared.

MEDICINE 39:6 1 © 2011 Elsevier Ltd. All rights reserved.

 IMAGING AND BIOPSY

occupying lesion of the renal tract as demonstrated on IVU.

Ultrasound may be required to differentiate a renal cyst from
a tumour. A non-radio-opaque calculus can produce a negative
filling defect within the contrast-filled collecting system similar
to a urothelial tumour.

Ultrasound (US)
The use of US in the assessment and follow-up of renal disease
has become widespread chiefly because of the absence of expo-
sure to radiation and its easy availability. An urgent US exami-
nation is indicated in the assessment of new-onset renal failure
to exclude urinary obstruction, especially in the context of
sepsis (Figure 1). If urinary obstruction is detected as
hydronephrosis and/or hydroureter, a US-guided nephrostomy
is often appro- priate to relieve urinary obstruction and
preserve renal function
(Figure 2). In chronic renal failure, the kidneys may be small
(normal size 10e12 cm) and hyperechoic. Asymmetry in renal
size may suggest renal artery stenosis and Doppler
interrogation of the renal artery may confirm this. Focal renal
scarring could be evidence of previous pyelonephritis or focal
renal ischaemia. Renal stones can be visualized, even if they are
not radio-opaque. Simple renal cysts can be confidently
diagnosed with US, whereas alternative imaging, such as CT or
magnetic resonance
imaging (MRI), will be required to exclude malignancy in atyp-
ical cysts (cysts other than thin-walled, unilocular fluid-filled
cysts, such as multi-loculated cysts and cysts containing
solid

MEDICINE 39:6 2 © 2011 Elsevier Ltd. All rights reserved.

 Renal cortex Normal calyces
a

Renal cortex Dilated calyx

b

Figure 1 Ultrasound scans. a Normal appearance of kidney with undilated pelvi-calyceal systems. b Dilated pelvi-calyceal system in a kidney due to due
to ureteric obstruction.

Contrast in the renal pelvis RT

Nephrostomy
catheter in the renal pelvis

Ureteric JJ stent,
with upper end in the renal pelvis and lower end in the bladder

Figure 2 Nephrostogram performed by contrast injection through the nephrostomy catheter shows contrast reaching the bladder through the ureteric
stent.
components). Further assessment of suspicious renal lesions is now also possible with contrast-enhanced renal US. In cases of
renal trauma, a perinephric haematoma can be demonstrated.
The presence of such extrarenal fluid should be a stimulus to
further investigation with a CT scan to exclude significant renal
parenchymal or vascular injury. Renal colour Doppler examina-
tion can be used to assess the patency of the renal artery and
vein.
Advantages: US can be used for bedside assessment and for real-
time guidance during renal intervention. There is no exposure of
the patient to radiation.
Disadvantages: include operator dependence and sub-optimal
image quality in obese patients.
Computed tomography (CT)
In many centres, CT has replaced IVU as the preferred imaging
modality for the diagnosis of urinary calculi (Figure 3). This scan
is usually performed without intravenous contrast enhancement.
a Obstructed calyces
Figure 3 Coronal reformatted images from a CT urogram shows a stone in the distal left ureter.
The modern multi-detector CT scanners allow acquisition of the
whole abdomen in a few seconds during a single breath-hold and
dedicated work-stations allow multi-planar interrogation of the
data acquired. If urolithiasis is not the cause of the patient’s
symptoms, this examination may help to identify other abdom-
inal causes. Renal masses can be assessed by a triple-phase CT
scan (unenhanced, arterial and delayed-phase acquisitions). The
unenhanced scan will demonstrate any soft-tissue calcification
or fat in renal tumours (angiomyolipoma). Subsequent scans will
assess the response of the lesion to contrast and, if malignant,
stage the lesion with regard to vascular involvement, lymph
node and metastatic spread (Figure 4).
Advantages: CT scans have high spatial resolution and the ability
to assess all the other abdominal viscera. The image quality is
relatively independent of body habitus and bowel gas.
Disadvantages: radiation exposure is 10 times that of a chest
radiograph. When patients with renal impairment (especially if
associated with diabetes mellitus) are given intravenous contrast
in left kidney
Right kidney
Right ureter Left ureter
Ureteric stone near
vesico ureteric junction

Figure 4 CT scan of the abdomen with intravenous contrast enhancement shows a mass in the right kidney.
agents, there is a small risk of contrast-induced nephropathy.
Adequate hydration before the scan can reduce this risk.
Magnetic resonance imaging (MRI)
MRI scans are obtained by interrogating the body of the patient
with radiofrequency pulses whilst in a magnetic field. The main
role of renal MRI is the assessment of renal arteries by MR
angiography (Figure 5). Atherosclerotic disease, which most
commonly affects older men, typically involves the proximal
third of the main renal artery. Fibromuscular dysplasia, more
common in younger women, usually affects the distal two-thirds
of the renal artery and its branches. MRI may overestimate the
severity of renal arterial stenosis. MRI can be used to evaluate
potential live renal donors prior to renal transplantation.
The renal parenchyma, collecting system and vascular anatomy
can all be assessed. Multiple renal arteries can be identified in
such potential donors.
Figure 5 a Reformatted image from CT angiogram shows stenosis in the renal artery of a renal transplant patient. b Balloon angioplasty of renal artery
stenosis. c CT angiogram shows resolution of the renal artery stenosis after angioplasty.
Large bowel Small bowel
Right lobe of liver Left kidney
Renal mass
Right kidney
Inferior vena cava Aorta
Advantages: images of supreme contrast resolution can be
obtained in multiple planes. No X-rays are involved.
Disadvantages: scans are relatively lengthy and therefore
susceptible to patient movement. The patient may become
claustrophobic within the scanner and be unable to complete the
examination. When patients with renal impairment are given
gadolinium contrast agents, there is a risk of nephrogenic
systemic fibrosis.
Digital subtraction angiography (DSA)
DSA is usually performed to confirm the findings from non-inva-
sive techniques before proceeding to endovascular treatment; in
the case of renal artery stenosis, this would take the form of
balloon catheter angioplasty and, if appropriate, renal artery
stent insertion. In cases of haematuria, DSA can be used to
identify the source of bleeding, which may arise from renal
tumours (e.g. renal
 Liver
a Pancreas

Superior
mesenteric artery

Large bowel

Right
Anteriorly
kidney
displaced left kidney
Inferior vena Retroperitoneal haematoma
cava

Main renal artery

b

Contrast extravasation
Catheter in left showing the area
renal artery of haemorrhage

Aorta
c

Embolization coils

Catheter with tip in left renal artery

Figure 6 a CT scan with contrast enhancement shows a haematoma behind the left kidney. b Catheter angiogram shows the site of haemorrhage from the
left kidney. c Catheter angiogram after selective embolisation of the renal artery branch shows cessation of bleeding.

Figure 7 Sequential images from a dynamic radionuclide scan shows delayed emptying with dilated pelvicalyceal system in right kidney and dilated
right ureter. Normal emptying of the left kidney.
cell carcinoma, angiomyolipoma) or iatrogenic arterial injury
following renal biopsy. Life-threatening bleeding in these
instances can be controlled by selective embolization while
preserving the function of the rest of the kidney (Figure 6).
Isotope studies
Radionuclide investigations provide functional and quantitative
information to supplement the structural information provided
by other imaging techniques. There are two broad categories,
dynamic and static renal scans. A dynamic renal scan can be used
to measure total function, differential blood flow and differential
renal function, to give a quantitative evaluation of the rate of
transit through the urinary tract. This is useful when assessing
whether chronically dilated collecting systems are obstructed
(Figure 7). A static renal scan can be used to assess divided renal
function and is helpful in detecting renal cortical scars in
children with urinary tract infections. Further investigation of
these chil- dren would involve micturating cystography (a
dynamic contrast X-ray examination of the bladder) to look for
vesico-ureteric reflux. The radiopharmaceuticals used in static
scans are taken up by the renal parenchyma with no significant
excretion.
Renal transplant assessment
Renal transplants are placed in the right or left iliac fossa, and as
they are relatively superficial compared to native kidneys, they
are readily assessed using US. In the immediate postoperative
period, colour Doppler US can be used to assess kidney perfusion
and measure the intrarenal resistive index. The resistive index is
a measure of resistance to arterial flow in the renal vascular bed;
values less than 0.8 are normal, but values more than 0.9 are
suggestive of transplant dysfunction. In addition to measuring
LEFT RIGHT
Normal left kidney
Obstructed
right kidney Right ureter
Bladder
the flow in the main transplant artery, the patency of the renal
vein can also be confirmed. Also, the presence of extrarenal
collections (haematomas, lymphoceles or urinomas) can be
identified. Dilatation of the collecting system may be indicative
of obstruction (Figure 7).
Image-guided biopsy and treatment
US can be used to provide real-time guidance during a renal
biopsy. A renal biopsy is usually performed for evaluation of
renal diseases, which may present as acute kidney injury or
chronic kidney disease (e.g. glomerulonephritis or interstitial
nephritis), and to diagnose graft rejection in cases of transplant
dysfunction. Biopsy of focal renal masses is not usually per-
formed if the lesion is to be surgically removed. However, biopsy
may be indicated if the patient is to be treated non-surgically
with chemotherapy or there is a suspicion that the lesion
may be a renal metastasis or lymphoma.
Image-guided ablative therapies, such as radiofrequency
ablation or cryotherapy, can be used to treat focal renal lesions
including tumours, thereby preventing surgical nephrectomy
and preserving renal function. This form of treatment is
minimally invasive and associated with less morbidity than
open surgery. A
FURTHER READING
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Fukuda M, Cosgrove DO. Abdominal ultrasound. A basic textbook. Tokyo:
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Grainger RG, Allison D, Adam A, Dixon AK. Diagnostic radiology. 4th edn.
London: Churchill Livingstone, 2002.