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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
Early dynamic scan following a bolus injection of contrast media can give further hemodynamic information. Non-contrast CT scan is useful in detecting renal parenchymal calcifications. The prominent renal pathologic findings in HFRS are renal swelling. Obliteration of the corticomedullary contrast on T1-weighted MRI is regarded as a sensitive but non-specific finding of renal parenchymal diseases. Paroxysmal . MRI provides superb soft tissue contrast which is better than that of CT. Contrast-enhanced CT scan may reveal the pattern of contrast enhancement and excretion in patients with impaired renal function. which may be different among the types of ARF. intense congestion and hemorrhage in the renal medulla accompanied by acute tubular necrosis. In the course of ARF. Delayed scan without further injection of contrast media can sometimes provide valuable information by demonstrating the pattern of washout and delayed contrast enhancement. and a variable degree of renal failure. The use of CT in renal parenchymal diseases is very limited. MRI is very sensitive in demonstrating the hemorrhage and iron deposition. 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 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.2 kidney. while corticomedullary contrast is decreased on T2weighted images. This finding represents intense congestion and hemorrhage in the outer part of the medulla. Hemorrhagic fever with renal syndrome (HFRS) is an acute infectious disease caused by Hanta virus and clinically characterized by fever. 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. most of the normal kidneys show distinct contrast between the cortex and the medulla. renal functional status may change rapidly. On T1weighted MRI. visceral hemorrhage. 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. 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.
and T2-weighted images. and extreme muscle activity. Unlike the other renal parenchymal diseases in which corticomedullary contrast is lost on T1-weighted MRI. The major causes of rhabdomyolysis include trauma. This CT finding of delayed contrast . Myoglobinuric renal failure is the most commonly recognized cause of morbidity and mortality in patients with rhabdomyolysis. alteration of renal blood flow. Patchy or wedge-shaped areas of poor contrast-enhancement are seen in various causes of ARF and renal infection.and T2-weighted images.3 nocturnal hemoglobulinuria (PNH) is a hemolytic disorder caused by an increased sensitivity to complement-mediated erythrocyte lysis. the kidney is enlarged and high-signal-intensity lesions are observed in the renal cortex on both T1. Acute renal cortical necrosis represents a rare cause of ARF and is characterized by necrosis of the renal cortex and sparing of the medulla. The resultant MRI finding is a marked decrease of the cortical signal intensity on both T1. the attenuation of the renal cortex is slightly higher than that of the medulla. protein. and tubular obstruction secondary to precipitation of myoglobin. preservation of the corticomedullary contrast on T1-weighted images with globular renal swelling is a constant finding in patients with ARF secondary to rhabdomyolysis. In its chronic phase. and uric acid crystals. ischemic and thermal muscle injuries. 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. On CT scan without contrast enhancement. In acute phase. Similar imaging findings may be seen in patients with sickle cell disease and in mechanical hemolysis due to malfunctioning prosthetic cardiac valve. Rhabdomyolysis is a condition in which injury to skeletal muscles results in leakage of intracellular contents of myocytes into the plasma. The most commonly proposed theories explaining the development of ARF in patients with rhabdomyolysis are direct nephrotoxicity of the components of myoglobin. 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. 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. exposure to drugs and toxins.
including excretory urography. 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. 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. Doppler US. In conclusion. recovery phase on rhabdomyolysis-related ARF. Although various radiologic approaches have been used to diagnose thrombosis of the renal vein. and acute focal bacterial nephritis. US. The MRI. and MRI have their own advantages and limitations in the evaluation of renal parenchymal diseases. However. and radionuclide imaging have been used. are often difficult to see. MRI may demonstrate the lesions by the changes of the signal intensity. 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. CT. hepatorenal syndrome. This MRI finding probably represents congestion and hemorrhage in the renal medulla. . HFRS. however. and the radiologists should be aware of them for adequate evaluation of the patients with renal parenchymal diseases.and T2weighted images. CT. The common MR findings of renal infarction are low signal intensity of the lesion on both T1.4 enhancement has been reported in ARF induced by a transient circulatory insufficiency from dehydration and diarrhea. 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. especially postcontrast MRI. Thrombi in the renal vein. and renal parenchymal changes are not specific enough for the diagnosis. 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. exercise-induced ARF with patchy renal vasoconstriction.
et al. Kim CW Duplex Doppler US in patients with medical renal disease: resistive index vs serum creatinine level. Han JK. Diabetes Research and Clinical Practice 1992. 8. et al. 16:924-928 Kim SH. Kim SM. 6. Lee JS MR imaging of acute renal cortical necrosis: a case report. Infarction of the kidney: role of contrast enhanced MRI. Lee JS. 3. Kim S Paroxysmal nocturnal hemoglobinuria: case report of MR imaging and CT findings. Lee JS. MR imaging of the kidney. Han MC. 7. Radiology 1990. Han MC. 18:75-81 Kim SH. JCAT 1991. Clin Radiol 1992. Lee HK. et al. Choi BI. Kim WH. Lee JS Acute renal failure secondary to rhabdomyolysis: MR imaging of the kidney. Kim S.5 SUGGESTED READING 1. 15:985-988 Kim SH. Hemorrhagic fever with renal syndrome. Han MC. CT and MR findings. Kim S. Kim S. Han MC Diabetic nephropathy: duplex Doppler ultrasound findings. Han JS. 175:823-825 Kim SH. Acta Radiol 1991. 4. 5. 32:315-316 Kim SH. . Acta Radiol 1992. Lee JS. 33:431-433 Kim SH. Han MC. Kim S. Exercise-induced acute renal failure and patchy renal vasoconstriction. Acta Radiol 1992. 33:573-576 Kim SH. 45:85-87 2. Park JH. JCAT 1992. Kim SH.
AJR 1994. et al. JCAT 1999. 11. Park JH. Kim SH. Doppler sonography in experimentally induced acute renal failure in rabbits: resistive index versus serum creatinine levels.6 9. Yoon CJ Hemosiderin deposition on the renal cortex by mechanical hemolysis due to malfunctioning prosthetic cardiac valve: report of MR findings in two cases. Kim SH. et al. Byun HS. . Renal parenchymal abnormalities associated with renal vein thrombosis: correlation between MR imaging and pathologic findings in rabbits. 30:168-172 Lee JW. Kim HD. Invest Radiol 1995. 23:445-447 10. 162:1361-1365 Yoon DY. Kim SH.
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