ORIGINAL ARTICLE

CORRELATION OF RENAL LENGTH AND CORTICAL THICKNESS

MEASURED ON ULTRASOUND WITH THE DEGREE OF RENAL
IMPAIRMENT IN CHRONIC KIDNEY DISEASE
Samia Rauf, Imran Masoud Qasmi, Kaukab Javed, Irfan khattak, Ghias Khan,
Syed Farrukh Nadeem, Nazia Dildar
De partm e ntofRadiol
ogy, Arm e d Force s Ins titute ofRadiol
ogy and Im aging (AFIRI), Raw al
pindi, Pak is tan.

PJR July - September 2014; 24(3): 77-82

ABSTRACT

INTRODUCTION: As th e burde n of ch ronic k idne y dis e as e (CK D) continue s to incre as e , e fforts to re duce th e
cos t of m onitoring and m anaging th is dis e as e are ne e de d. Aim of th is s tudy is to e val uate th e us e ful ne s s of a
ge ne ral ly obtainabl e m e as ure m e nt atul tras ound in th e s e tting of CK D as a corre l ate to k idne y function. In th is
s tudy w e de te rm ine d th e corre l ation of ul tras ound m e as ure d re nall e ngth and re nalcorticalth ick ne s s w ith
e s tim ate d glom e rul tration rate (e GFR). METHODOLOGY: From Nove m be r 2011 to M arch 2013, Tw o h undre d
ar fil
(114 m e n and 86 w om e n, m e an age 50 ye ars ) cl inical ly diagnos e d cas e s of CK D not on dial ys is w e re s tudie d.
Th e patie nts w e re from a s ingl e ins titution. Es tim ate d GFR w as de te rm ine d us ing Cock croftand Gaul te q uation.
Re nall e ngth and corticalth ick ne s s w e re as s e s s e d ul tras onograph ical l
y. Th e re lations h ips be tw e e n th e re nal
le ngth and corticalth ick ne s s w ith e GFR re s pe ctive l y w e re as s e s s e d us ing Spe arm an’s corre l ation coe fficie nt.
RESUL TS: A s tatis tical l
y s ignificant, pos itive and s trong re l ations h ip w as obs e rve d be tw e e n e GFR and m e an
corticalth ick ne s s us ing th e CG e q uations (Pe ars on’s r val ue =0.59 6, s ig p val ue ). Th e re als o w as a s tatis tical l
y
s ignificantand pos itive , butw e ak re l ations h ip be tw e e n CG e GFR and m e an re nall e ngth (Pe ars on’s r val ue =0.216,
s ignificant p val ue ). CONCLUSION: Corticalth ick ne s s m e as ure d on ul tras ound appe ars to be m ore cl os e l
y
re late d to e GFR th an re nall e ngth . Re porting corticalth ick ne s s in patie nts w ith CK D w h o are not on dial ys is
s h oul d be cons ide re d.
Key words: Ch ronic k idne y dis e as e , re nalfunction, ul tras ound, re nall e ngth , re nalcorticalth ick ne s s

Introduction th e s e patie nts are e xam ine d.3 In dis e as e s invol ving
th e k idne ys , re nall e ngth and corticalth ick ne s s are
Th e burde n of ch ronic re nalfail ure (CRF) h as m e as ure d us ual l
y both atth e tim e ofdiagnos is and
incre as e d e xpone ntial ly and is cons um ing th e re s our- during fol ow - up.4,5 Th e s e m e as ure m e nts can be
l
ce s of both de ve l ope d and de ve l oping e conom ie s , m ade us ing s onograph y.6,7
and e fforts to re duce th e cos t of m anaging th is Traditionalte ach ing is th at re nall e ngth corre l ate s
dre adfuldis e as e are al w ays w e l
com e d.1 w ith re nalfunction in ch ronic k idne y dis e as e (CK D),
Ul tras ound w as found to be a rapid, e ffe ctive , radi- and th e re fore bipol ar re nall e ngth s are al m os talw ays
ation- fre e , portabl e and s afe im aging m odal ity. 2 re porte d at re nalul tras ound. It is al
8 s o taugh t th at
Be caus e abnorm al itie s ofk idne y s iz e are pre s e ntin e GFR is be tte r th an rais e d s e rum cre atinine al one ,
m any re naldis e as e s , it is val uabl e to h ave a s e t of in as s e s s ing s e ve rity ofk idne y dis e as e . 9

s tandard s onograph ic m e as ure m e nts to us e w h e n Late r s tudie s h ave s h ow n th atre nalvol um e cal culate d
Correspondence : Dr. Sam ia Rauf
De partm e ntofRadiol ogy,
Arm e d Force s Ins titute ofRadiol ogy and
Im aging (AFIRI), Raw al pindi, Pak is tan.
Em ail: raufs am ia@ yah oo.com
Subm itte d 1 M arch 2015, Acce pte d 13 March 2015

PA K I S TA N J O U RN AL O F R A D I O L O GY PJR July - September 2014; 24(3) 77

at ul tras ound is a m ore e xact m e as ure m e nt of a atul tras ound in th e s e tting ofCK D as a corre l ate to
functioning k idne y th an re nall e ngth . Progre s s ive k idne y function (e GFR).
re nalarte ry s te nos is h as be e n s h ow n to be as s o- Th e aim ofth e s tud w as to de te rm ine th e corre l ation
ciate d w ith progre s s ive re duction ofre nall e ngth .10,11 be tw e e n ul
tras ound m e as ure d re nall e ngth and re nal
A s tudy e val uating patie nts w ith s us pe cte d unil ate ral corticalth ick ne s s w ith e s tim ate d gl
om e rular fil
tration
re nalarte ry s te nos is s h ow e d re nalvol um e w as a rate (e GFR).
be tte r pre dictor of s ingl e -k idne y GFR th an re nal
le ngth . Th e y al s o s h ow e d th e addition of re nalare a
and pare nch ym alth ick ne s s m e as ure d atul tras ound
Materials and Methods
to l e ngth w as a be tte r pre dictor ofboth s ingl e -k idne y
Th is w as de s criptive cros s s e ctionals tudy conducte d
GFR and re nalvol um e th an l e ngth m e as ure d at
at Arm e d Force s Ins titute of Radiol ogicalIm aging
ul tras ound al one . A m ore re ce nts tudy s h ow e d th at
(AFIRI), Raw al pindi from Nove m be r 2011 to M arch
k idne y l e ngth and vol um e s ignificantl y corre l ate d
w ith e s tim ate d gl om e rul ar fil tration rate (e GFR) in 2013.S am pl e s iz e w as cal cul ate d us ing PAS S
th e e lde rl y, butk idne y l e ngth h as a l ow s pe cificity in s oftw are ve rs ion-11 us ing corre l ation coe fficie nt (r)
pre dicting re nalim pairm e nt. H ow e ve r, m e as uring 0.371 of ul tras ound m e as ure d re nall e ngth w ith
th e true k idne y vol um e at ul tras ound is difficul t. e GFR as fol
12 l
ow s :-
Es tim ate s of vol um e can be m ade on th e bas is of
th e e llips oid form ul a, butth is m e th od h as an inh e re nt Numeric Results when Ha: R0<>R1
de fe ctbe caus e th e k idne y is notactual lyel lips oid.12 Pow e r N Al ph a Be ta R0 R1
In addition, th e e l l
ips oid vol um e w oul d incl ude th e 0.9 0304 72 0.05000 0.09 69 6 0.00000 0.37100
ce ntrals inus fat th at doe s not contain functioning
re naltis s ue and doe s vary from patie nt to patie nt. A s am pl e s iz e of 72 ach ie ve s 9 0% pow e r to de te ct
Th e s e factors l ik e l
y contribute d to th e findings in a a diffe re nce of- 0.37100 be tw e e n th e nul lh ypoth e s is
re ce nt s tudy th at s h ow e d a pos itive , but w e ak corre lation of0.00000 and th e al te rnative h ypoth e s is
as s ociation be tw e e n s onograph ical ly de te rm ine d corre l ation of0.37100 us ing a tw o-s ide d h ypoth e s is
k idne y vol um e and various indice s of gl om e rul ar te s tw ith a s ignificance le ve lof0.05000. H ow e ve r a
filtration rate (GFR). Th e s tudy s h ow e d a pos itive s am pl e s iz e of200 w as ach ie ve d for th e s tudy.
corre l ation be tw e e n K V and Cock croft and Gaul t
e s tim ate d GFR(r = 0.471, p= 0.003). Th e ave rage
k idne y l e ngth w as found to s ignificantl y corre l ate Operational Definitions
w ith e s tim ate d CrClby th e CG e q uation (r=0.371,
p=0.024).1 Renal Length: Th e gre ate s t pol e to pole dis tance
In patie nts w ith CK D, th e re nalcorticale ch oge nicity ofk idne y in s agittalpl ane on ul tras ound, m e as ure d
incre as e s atul tras ound. In addition, th e re nalcorte x in m il
lim e te rs (m m ).M e an re nall e ngth cal cul ate d
ofte n be com e s th inne d. A re ce nt s tudy s h ow s th at from bil ate ralm e as ure m e nts .
corticalth ick ne s s m e as ure d on ul tras ound appe ars
to be m ore cl os e l y re late d to e GFR th an re nall e ngth . Renal Cortical Thickness: Th e s h orte s t dis tance
Th e re w as a s tatis tical ly s ignificant re l ations h ip from th e bas e of m e dul lary pyram id to th e re nal
be tw e e n e GFR and cortical Th ick ne s s us ing CG caps ul e in s agittalpl ane at th e l e ve lof m id k idne y
(p < 0.0001). Al s o th e re w as a s tatis tical l
y Significant on ul tras ound, m e as ure d in m il
lim e te rs (m m ). M e an
re lations h ip be tw e e n CG and l e ngth (p = 0.003). re nalcorticalth ick ne s s cal cul ate d from bil ate ral
Re porting corticalth ick ne s s in patie nts w ith CK D m e as ure m e nts .
w h o are not on dial ys is s h oul d be cons ide re d.12
As th e burde n ofCK D continue s to incre as e , e fforts Estimated Glomerular Filtration Rate (eGFR):
to re duce th e cos t ofm onitoring and m anaging th is Cock croft and Gaul t(CG) e q uation w il
lbe us e d to
dis e as e are ne e de d. Our s tudy w il latte m ptto e val uate e s tim ate GFR (m e as ure d in m l/m in/1.73m 2) from
th e us e ful ne s s ofa ge ne ral ly obtainabl e m e as ure m e nt s e rum cre atinine as foll
ow s

PAK I S TA N J O U R N A L OF R A D I O LO GY PJR July - September 2014; 24(3) 78

 CrCl (CG) = (140-age) x lean body weight (Kg) x (1.22 male or 1.04 female)
Serum creatinine µ mol/ l

Cl inical ly diagnos e d cas e s of CK D, on th e bas is of Frequency Percent Valid Cumulative

im paire d re nalfunction for m ore th an 3 m onth s , from Percent Percent
both m al e s and fe m al e s , w ith an age l im it of 20-70 M al
e 114 57.0 57.0 57.0
ye ars w e re incl ude d in th is s tudy. Th e patie nts not
Val
id Fe m al
e 86 43.0 43.0 100.0
incl ude d in th e s tudy w e re th os e on dial ys is and
th os e h aving diabe te s m e l litus , h ydrone ph ros is or Total 200 100.0 100.0
adul tpol ycys tic k idne y dis e as e (In th e s e conditions Table 1: Ge nde r bas e d Fre q ue ncie s
k idne y s iz e us ual ly incre as e ) as pe r cl inicalre cord. Sex

Al s o th os e w ith e xtre m e s ofage s i.e . <20 ye ars and 120

>70 ye ars (h ave s m al le r k idne y s iz e s ) & w ith e xtre m e s

100
ofbody m as s (as e q uation for e GFR do notpe rform
we l lin s uch cas e s ) w e re al s o notincl ude d. 80

Data collection Procedure: Ul tras ound m e as ure - 60

m e nts w e re pe rform e d by th e prim ary auth or w h ich

40

w as re vie w e d by a cons ul tant h aving 5 ye ars of

e xpe rie nce . Righ t, le ftand m e an m e as ure m e nts w e re 20

tak e n. Th e e xam inations w e re pe rform e d us ing s tan-

dard gre y-s cal e B- m ode im aging w ith a 3.5-M H z 0
male female

Sex
curvil ine ar trans duce r ofAl ok a SSD 5500 ul tras ound
Figure 1: Graph s h ow ing ge nde r bas e d dis tribution ofcoh ort.
m ach ine . Th e e xam ination be gan w ith th e s ubje ct
s upine ;th e pre aortic re gion w as e xam ine d to e xcl ude
th e pre s e nce ofa h ors e s h oe k idne y. Re nalm e as ure - Result
m e nts w e re obtaine d w ith th e s ubje ctprone . Le ngth
and corticalth ick ne s s ofth e k idne y w e re m e as ure d Th e m e an corticalth ick ne s s w as 9 .12 m m (range ,
bil ate ral l
y. Patie nt’s s e rum cre atinine l e ve lm e as ure d 2.7–19 .4 m m ). Th e m e an l e ngth w as 9 5.9 5 m m
in M H l aboratory during pre vious one m onth w e re (range , 48.86 - 124.10 m m ). A s tatis tical l
y s ignificant,
us e d to e s tim ate G FR by Cock croft and G aul t pos itive and s trong re l ations h ip w as obs e rve d
be tw e e n e GFR and m e an corticalth ick ne s s us ing
e q uation. Al lth e inform ation and m e as ure m e nts w e re
th e CG e q uations (Pe ars on’s r val ue = 0.59 6, s igni-
re corde d on a “Data Col le ction Pe rform a”.
ficantp val ue ). Th e re al
s o w as a s tatis tical
ly s ignificant
Data anal ys is Data w as e nte re d and anal yz e d us ing
and pos itive , but w e ak re l ations h ip be tw e e n CG
SPSS ve rs ion-20. De s criptive s tatis tics w as cal cul ate d
e GFR and m e an re nall e ngth (Pe ars on’s r val ue =
for both q ual itative and q u antitative variabl es. 0.216, s ignificantp val ue ). Th e s tronge s tre lations h ip,
Qual itative variabl e incl ude ge nde r and th is w as as e vide nce d by th e h igh e s t Pe ars on’s r val ue , w as
pre s e nte d as fre q ue ncy/pe rce ntage . Quantitative for m e an corticalth ick ne s s and CG e GFR (Pe ars on’s
variabl e s age , w e igh t, ul tras ound m e as ure d re nal r value =0 .59 6) (Tab. 2 and 3).
le ngth , ul tras ound m e as ure d re nalcorticalth ick ne s s ,
s e rum cre atinine l e ve land e s tim ate d gl om e rul ar
filtration rate (e GFR) and th e s e w e re pre s e nte d as
M e an ± S D. Tabl e s and ch arts w e re m ade for Discussion
q ual itative variabl e s . Pe ars on’s r corre l ation val ue
and Sig (2-tail e d) val ue w e re cal cul ate d for re nal Our s tudy s h ow e d a s tatis tical
ly s ignificantre l
ations h ip
le ngth ve rs us e GFR and re nalcorticalth ick ne s s be tw e e n corticalth ick ne s s m e as ure d atul tras ound
ve rs us e GFR. P-val ue l e s s th an 0.01 w as cons ide re d and re nalfunction in patie nts w ith CK D. Th e re w as
s ignificant. als o a s ignificant re l ations h ip be tw e e n CG e GFR

PAK I S TA N J O U R N A L OF R A D I O LO GY PJR July - September 2014; 24(3) 79

 N Minimum Maximum Mean
Std. m e as ure d at ul tras ound al one . 13 Anoth e r s tudy
Deviation s h ow e d a corre l ation be tw e e n e GFR and re nal
Age 200 20.00 70.00 50.8500 17.38357
vol um e s m e as ure d at ul tras ound in 116 h e al th y
Wt 200 37.00 110.00 63.1500 12.29 035
ch il dre n. 14 O th e r auth ors h ave de s cribe d k idne y
Cr 200 66.00 149 3.00 300.89 45 309 .70758
vol um e as a be tte r pre dictor of re nalfunction th an
e GFR 200 3.47 149 .85 41.6658 35.62370
re nall e ngth . 15,16 Th is w as furth e r s upporte d by a
RL.R 200 7.9 0 126.10 9 5.0741 16.15370
s tudy in 2009 by Sanus i e t al . 1 s h ow ing a w e ak but
RL.L 200 62.00 132.80 9 7.469 3 14.289 15
pos itive corre l ation be tw e e n k idne y vol um e and
RL.M 200 48.86 124.10 9 5.9 537 14.219 32
various indice s ofGFR, be s tw ith m e as ure d cre atinine
RCT.R 200 2.30 18.50 9 .1019 3.59 463
cl e arance , in 40 patie nts w ith CK D. Th e ir re s ul ts also
RCT.L 200 2.70 20.30 9 .1758 3.35660
RCT.M 200 2.70 19 .40 9 .1213 3.3439 2
s h ow e d a s ignificant corre l ation w ith th e m e as ure d
Val
id N 200
cre atinine cl e arance and th e CG and M DRD e q ua-
(l
is tw is e )
tions , furth e r val idating th e s e e s tim ate s of GFR in
Table 2: De s criptive Statis tics
CK D.1 In m y s tudy re nalcorte x m e as ure m e nts w e re
tak e n pe rpe ndicul ar to th e re nalcaps ul e from th e
eGFR RL.M RCT.M caps ul e to th e corticom e du l lary inte rface . Th is
Pe ars on Corre lation 1 .216** .59 6** inte rface can be difficul tto ide ntify in s om e patie nts
e GFR Sig. (2-tailed) .002 .000 in w h om th e re is poor corticom e dul lary diffe re n-
N 200 200 200 tiation. Additionalm e as ure m e nts in th e trans ve rs e
Pe ars on Corre lation .216** 1 .267** pl ane or an ave rage corticalth ick ne s s incl uding th e
RL.M Sig. (2-tailed) .002 .000 uppe r and l ow e r pol e s m ay prove to be a be tte r
N 200 200 200 re pre s e ntation of functioning pare nch ym alvol um e
Pe ars on Corre lation .59 6** .267** 1 in future s tudie s .
RCT.M Sig. (2-tailed) .000 .000 O ur s tudy onl y e val uate d patie nts w ith CK D and
N 200 200 200 patie nts on dial ys is w e re ne ce s s aril y e xcl ude d from
**. Corre l
ation is s ignificantatth e 0.01 l
e ve l(2-tail
e d). th is s tudy. Exam ining th e re l ations h ip be tw e e n re nal
Table 3: Corre l
ations function on th e bas is ofs e rum cre atinine and cortical
and re nall e ngth . Re nall e ngth h as traditional l
y be e n th ick ne s s w oul d be inh e re ntl y fl aw e d in th is group
cons ide re d a s urrogate m ark e r of re nalfunction be caus e th e cre atinine us e d for cal cul ation w oul d
be caus e re nall e ngth de cre as e s w ith de cre as ing be a m e as ure ofdial ys is e fficacy rath e r th an native
re nalfunction. Re nall e ngth s are unive rs al l
y re porte d re nalfunction.
and are us ual ly th e onl y m e as ure m e nts give n at Pote ntiall im itation ofm y s tudy is th e us e ofcom pu-
re nalul tras ound.2 H ow e ve r, on th e bas is ofours tudy; tationale s tim ate s of re nalfunction, rath e r th an
it appe ars th at corticalth ick ne s s m e as ure d at m e as ure d GFR. Al th ough CG form ul a h as be e n
ul tras ound m ay be re l ate d m ore cl os e l
y to e GFR pre vious l y val idate d. 17,18 A s tudy by Rul e e t al.19 in
th an re nall e ngth in patie nts w ith ch ronic re nalfail ure . 2004 s h ow e d th atth e M DRD e q uation s ys te m atical ly
O ur s tudy atte m pte d to e val uate th e us e ful ne s s of unde re s tim ate d re nalfunction. Th e unde re s tim ation
a ge ne ral l
y obtainabl e m e as ure m e nt at ul tras ound w as m uch m ore pronounce d for h e al th y volunte e rs
in th e s e tting ofCK D as a corre l ate to k idne y function (29 % unde re s tim ation) th an in patie nts w ith CK D
(e GFR). Prior s tudie s al s o h ave e val uate d im aging (6.2% unde re s tim ation). H ow e ve r, th e ir s tudy w as
m e as ure m e nts as s urrogate m ark e rs ofre nalfunction. pe rform e d w ith a ve rs ion of th e M DRD e q uation
A s tudy e val uating 69 patie nts w ith s us pe cte d be fore s tandardiz ation of cre atinine e s tim ate s be t-
unil ate ralre nalarte ry s te nos is s h ow e d re nalvol um e we e n l aboratorie s . Th e de ve l opm e nt ofth e ID–M S-
w as a be tte r pre dictor of s ingl e -k idne y GFR th an trace abl e M DRD s tudy e q uation th at w as us e d in
re nall e ngth . Th e y al s o s h ow e d th e addition ofre nal th e ir s tudy h as al low e d th e us e of s tandardiz e d
are a and pare nch ym alth ick ne s s m e as u re d at cre atinine m e as ure m e nts and s h oul d m inim iz e
ul tras ound to l e ngth w as a be tte r pre dictor of both m e as ure m e nt diffe re nce s . 20 A s l igh tly m ore re ce nt
s ingl e - k idne y GFR and re nalvol um e th an l e ngth s tudy dire ctl y com paring CG and M DRD e s tim ate s

PAK I S TA N J O U R N A L OF R A D I O LO GY PJR July - September 2014; 24(3) 80

of GFR in patie nts w ith CK D s h ow e d th e M DRD 6. Bak k e r J, O l
re e M , K aate e R, e tal
. Re nalvol um e
e q uation to be m ore accurate th an th e CG e q uation m e as ure m e nts : accuracy and re pe atabil ity ofUS
in patie nts w ith m ode rate to advance d k idne y dis e as e com pare d w ith th at of M R im aging. Radiol ogy
and diabe tic ne ph ropath y.21 19 9 9 ;211: 623-8.

7. Em am ian SA, Nie l s e n M B, Pe de rs e n JF. Intra-

Conclusion obs e rve r and inte robs e rve r variations in s ono-
graph ic m e as ure m e nts of k idne y s iz e in adul t
Corticalth ick ne s s from th e caps ul e to corticom e - volunte e rs : a com paris on ofl ine ar m e as ure m e nts
dul l
ary inte rface at th e m id k idne y le ve lm e as ure d and vol um e tric e s tim ate s . Acta Radiol19 9 5;36:
on ultras ound appe ars to be m ore cl os e l
y re late d to 39 9 -401.
e GFR th an re nall e ngth . Re porting corticalth ick ne s s
in patie nts w ith CK D w h o are noton dial ys is s h ould 8. Am e rican Col le ge of Radiol ogy W e bs ite . ACR
be cons ide re d. practice guide l ine for th e pe rform ance ofan ul tra-
s ound e xam ination ofth e abdom e n and/or re tro-
pe ritone um (in col laboration w ith th e Am e rican
References Ins titute ofUltras ound in Me dicine AIUM). Avail abl e
from : h ttp://w w w .acr.org/S e condaryM ainM e nu
Cate gorie s /q ual ity_ s afe ty/guide l
ine s /us /us _ abd
1. Sanus i AA, Arogundade FA, Fam ure w a O C, e t
om e n_ re tro.as px. Re vis e d 2007.
al . Re l
ations h ip oful tras onograph ical
ly de te rm ine d
k idne y vol um e w ith m e as ure d GFR, cal culate d
9 . Tam iz uddin S, Ah m e d W . K now l e dge , attitude and
cre atinine cl e arance and oth e r param e te rs in
practice s re garding ch ronic k idne y dis e as e and
ch ronic k idne y dis e as e (CKD). Ne ph rolDialTrans -
e s tim ate d GFR in a te rtiary care h os pitalin Pak is tan.
pl ant 2009 ;24: 169 0-4.
J Pak M e d As s oc M ay 2010;64(5): 342-6.
2. M ah m ood T, Younus R, Ah m ad F, M e m on S,
10. Sch re ibe r M J, Poh lM A, Novick AC. Th e natural
M oavia A. Ul tras ound as a re l
iabl
e guidance s ys -
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