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DOPPLER ULTRASOUND, CT AND MR IMAGING IN THE


STUDY OF RENAL PARENCHYMAL DISEASES

Seung Hyup KIM, MD

Renal parenchymal disease or medical renal disease is a term used to describe


diffuse renal disease involving renal parenchyma usually bilaterally, which should
be managed medically and not surgically. The imaging studies using intravenous
contrast media should be performed with caution since they may aggravate
already impaired renal function. US is usually the initial imaging study since
obstructive and non-obstructive causes of renal functional impairment can be
distinguished easily with US in most cases.

The US findings of renal parenchymal diseases are quite non-specific, but


Doppler US has expanded the role of US in the evaluation of renal parenchymal
diseases. Doppler US is an easy and non-invasive technique for evaluation of
renal blood flow. Color and power Doppler US easily demonstrate the general
increase or decrease of renal parenchymal blood flow, and hemodynamic
changes of the renal blood flow can be assessed by Doppler spectral analysis.
Renal resistive index (RI) [(peak systolic–end diastolic)/peak systolic] declines
from the segmental artery in the renal hilar region to the interlobular arteries in
the periphery of the renal cortex. Among these vessels, interlobar artery is the
best site to obtain Doppler spectrum for the evaluation of hemodynamic changes
in the renal parenchyma. The upper normal limit of RI is considered 0.7 and
mean normal value is around 0.6. Certain factors such as age, systemic blood
pressure, and heart rate may affect RI.

Renal parenchymal diseases primarily involving tubulointerstitial or vascular


compartments generally result in an elevated RI, whereas diseases limited to the
glomeruli do not. Examples in which RI is elevated and correlates well with the
severity of the disease include diabetic nephropathy, hepatorenal syndrome, and
hemolytic uremic syndrome. Although renal US is commonly performed in
patients with acute renal failure (ARF) as the initial imaging study, the findings
are usually non-specific changes of renal size and echogenicity. Doppler US
may provide additional information regarding the hemodynamic status of the
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kidney, which may be different among the types of ARF. RI is elevated in about
90% of renal type ARF accompanying acute tubular necrosis while only 20% of
patients with prerenal ARF shows elevated RI. In the course of ARF, renal
functional status may change rapidly. Doppler US may be useful because it can
provide real-time information regarding the hemodynamic changes of the kidney
and the examination can be repeated easily. An animal study to investigate the
temporal relation between the change in the Doppler RI and that of serum
creatinine level in the course of reversible ARF revealed that the changes in RI
preceded the changes in serum creatinine levels. This result suggests that the
repeated Doppler US with monitoring the changes of RI may be useful in
predicting the course of ARF and in judging the policy of the management.

The use of CT in renal parenchymal diseases is very limited. Non-contrast CT


scan is useful in detecting renal parenchymal calcifications. Contrast-enhanced
CT scan may reveal the pattern of contrast enhancement and excretion in
patients with impaired renal function. Early dynamic scan following a bolus
injection of contrast media can give further hemodynamic information. Delayed
scan without further injection of contrast media can sometimes provide valuable
information by demonstrating the pattern of washout and delayed contrast
enhancement.

MRI provides superb soft tissue contrast which is better than that of CT. On T1-
weighted MRI, most of the normal kidneys show distinct contrast between the
cortex and the medulla, while corticomedullary contrast is decreased on T2-
weighted images. Obliteration of the corticomedullary contrast on T1-weighted
MRI is regarded as a sensitive but non-specific finding of renal parenchymal
diseases.

MRI is very sensitive in demonstrating the hemorrhage and iron deposition.


Hemorrhagic fever with renal syndrome (HFRS) is an acute infectious disease
caused by Hanta virus and clinically characterized by fever, visceral hemorrhage,
and a variable degree of renal failure. The prominent renal pathologic findings in
HFRS are renal swelling, intense congestion and hemorrhage in the renal
medulla accompanied by acute tubular necrosis. The constant and characteristic
MRI finding of the kidney in HFRS is low signal intensity band along the outer
portion of the medulla on T2-weighted images. This finding represents intense
congestion and hemorrhage in the outer part of the medulla. Paroxysmal
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nocturnal hemoglobulinuria (PNH) is a hemolytic disorder caused by an


increased sensitivity to complement-mediated erythrocyte lysis. The typical
histologic finding of the kidney in PHN is a deposition of hemosiderin in
epithelial cells of the proximal convoluted tubules in the renal cortex. The resultant
MRI finding is a marked decrease of the cortical signal intensity on both T1- and
T2-weighted images. On CT scan without contrast enhancement, the attenuation
of the renal cortex is slightly higher than that of the medulla. Similar imaging
findings may be seen in patients with sickle cell disease and in mechanical
hemolysis due to malfunctioning prosthetic cardiac valve.

Acute renal cortical necrosis represents a rare cause of ARF and is


characterized by necrosis of the renal cortex and sparing of the medulla. In acute
phase, the kidney is enlarged and high-signal-intensity lesions are observed in
the renal cortex on both T1- and T2-weighted images. In its chronic phase, MRI
shows thinned renal cortex of low signal intensity on both pulse sequences
representing fibrotic scar and calcification which may be more clearly seen on
plain film or non-contrast CT scan.

Rhabdomyolysis is a condition in which injury to skeletal muscles results in


leakage of intracellular contents of myocytes into the plasma. Myoglobinuric renal
failure is the most commonly recognized cause of morbidity and mortality in
patients with rhabdomyolysis. The major causes of rhabdomyolysis include
trauma, ischemic and thermal muscle injuries, exposure to drugs and toxins, and
extreme muscle activity. The most commonly proposed theories explaining the
development of ARF in patients with rhabdomyolysis are direct nephrotoxicity of
the components of myoglobin, alteration of renal blood flow, and tubular
obstruction secondary to precipitation of myoglobin, protein, and uric acid
crystals. Unlike the other renal parenchymal diseases in which corticomedullary
contrast is lost on T1-weighted MRI, preservation of the corticomedullary contrast
on T1-weighted images with globular renal swelling is a constant finding in
patients with ARF secondary to rhabdomyolysis.

Patchy or wedge-shaped areas of poor contrast-enhancement are seen in


various causes of ARF and renal infection. Delayed CT scan without further
injection of contrast media sometimes demonstrates focal areas of delayed
contrast enhancement and this procedure may be helpful in determining the
nature and the extent of the disease. This CT finding of delayed contrast
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enhancement has been reported in ARF induced by a transient circulatory


insufficiency from dehydration and diarrhea, hepatorenal syndrome, recovery
phase on rhabdomyolysis-related ARF, exercise-induced ARF with patchy renal
vasoconstriction, HFRS, and acute focal bacterial nephritis. MRI may
demonstrate the lesions by the changes of the signal intensity.

The diagnosis of renal infarction can usually be made on the basis of specific CT
findings including a sharply marginated area of poor contrast enhancement and
a high-attenuation cortical rim peripheral to the lesion. The common MR findings
of renal infarction are low signal intensity of the lesion on both T1- and T2-
weighted images. However, cases with high signal intensity of the lesion on both
pulse sequences have also been reported and the pathologic basis of the high
signal intensity of the lesion is probably related to a hemorrhagic component of
the infarct. The MRI, especially postcontrast MRI, can demonstrate the extent of
the infarction with an accuracy comparable to CT or angiography without the
danger of iodinated contrast media to which damaged kidneys are more
susceptible.

Although various radiologic approaches have been used to diagnose


thrombosis of the renal vein, the diagnosis mainly depends on the detection of
thrombi in the renal vein and therefore renal venography remains the principal
radiological technique used for diagnosis in spite of its invasiveness. Less
invasive techniques, including excretory urography, US, CT, and radionuclide
imaging have been used. Thrombi in the renal vein, however, are often difficult to
see, and renal parenchymal changes are not specific enough for the diagnosis.
MRI may show a layer of tissue with low signal intensity in the renal medulla in
patients with renal vein thrombosis and the findings have been reproduced in
rabbits following renal vein ligation. This MRI finding probably represents
congestion and hemorrhage in the renal medulla.

In conclusion, Doppler US, CT, and MRI have their own advantages and
limitations in the evaluation of renal parenchymal diseases, and the radiologists
should be aware of them for adequate evaluation of the patients with renal
parenchymal diseases.
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SUGGESTED READING

1. Kim SH, Kim S, Lee JS, et al.


Hemorrhagic fever with renal syndrome. MR imaging of the kidney.
Radiology 1990; 175:823-825

2. Kim SH, Han MC, Lee JS, Kim S


Paroxysmal nocturnal hemoglobinuria: case report of MR imaging and CT
findings.
Acta Radiol 1991; 32:315-316

3. Kim SH, Han MC, Han JS, et al.


Exercise-induced acute renal failure and patchy renal vasoconstriction.
CT and MR findings.
JCAT 1991; 15:985-988

4. Kim SH, Park JH, Han JK, et al.


Infarction of the kidney: role of contrast enhanced MRI.
JCAT 1992; 16:924-928

5. Kim SH; Han MC, Kim S, Lee JS


Acute renal failure secondary to rhabdomyolysis: MR imaging of the
kidney.
Acta Radiol 1992; 33:573-576

6. Kim SH, Han MC, Kim S, Lee JS


MR imaging of acute renal cortical necrosis: a case report.
Acta Radiol 1992; 33:431-433

7. Kim SH, Kim SM, Lee HK, Kim S, Lee JS, Han MC
Diabetic nephropathy: duplex Doppler ultrasound findings.
Diabetes Research and Clinical Practice 1992; 18:75-81

8. Kim SH, Kim WH, Choi BI, Kim CW


Duplex Doppler US in patients with medical renal disease:
resistive index vs serum creatinine level.
Clin Radiol 1992; 45:85-87
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9. Kim SH, Byun HS, Park JH, et al.


Renal parenchymal abnormalities associated with renal vein thrombosis:
correlation between MR imaging and pathologic findings
in rabbits.
AJR 1994; 162:1361-1365

10. Yoon DY, Kim SH, Kim HD, et al.


Doppler sonography in experimentally induced acute renal failure
in rabbits: resistive index versus serum creatinine levels.
Invest Radiol 1995; 30:168-172

11. Lee JW, Kim SH, Yoon CJ


Hemosiderin deposition on the renal cortex by mechanical hemolysis due
to malfunctioning prosthetic cardiac valve: report of MR findings
in two cases.
JCAT 1999; 23:445-447