ULTRASONOGRAPHIC MEASUREMENT OF KIDNEY-TO-AORTA RATIO AS

A METHOD OF ESTIMATING RENAL SIZE IN DOGS

AUGUSTIN MARESCHAL, MARC-ANDRÉ D’ANJOU, MAXIM MOREAU, KATE ALEXANDER, GUY BEAUREGARD

Renal size is an important parameter in the assessment of renal disease in dogs. However, because of the great
variability in body conformation, absolute renal measurements cannot solely be used when evaluating kidneys
with ultrasonography. The use of a ratio comparing renal length and aortic luminal diameter (K/Ao) was
investigated. After confirming the reproducibility of these measurements, K/Ao ratios were obtained in 92 dogs
without clinical evidence of renal disease. Left and right K/Ao ratios were statistically similar. Based on 95%
confidence intervals, renal size should be considered reduced if the K/Ao ratio is o5.5 and increased when
4 9.1. Veterinary Radiology & Ultrasound, Vol. 48, No. 5, 2007, pp 434–438.

Key words: aorta, dog, kidney, ratio, ultrasonography.

Introduction parallel planimetric area technique seems to be superior to

S EVERAL CANINE DISEASES may be associated with chang-
es in renal size.1,2 Thus, accurate assessment of renal
size can provide useful clinical information. Radiography
can be used in dogs to estimate renal size by comparing
renal length on ventrodorsal projections to the length of
the second lumbar vertebra.3 Because of the large variation
in body size and conformation among different breeds, a
normal ratio of 2.5–3.5 between these structures has been
proposed and remains commonly used. This ratio is con-
sidered to be more reliable than absolute renal measure-
ment, but it is limited by several factors. Indeed, kidneys
can vary in depth and inclination, resulting in variable ra-
diographic magnification and distortion that can affect the
ratio. Additionally, renal contour can be difficult to see in
normal dogs, particularly that of the right kidney. Any loss
in abdominal detail, such as due to peritoneal or retro-
peritoneal effusion or cachexia, can affect renal visibility.
More invasive techniques such as excretory urography can
be used to improve renal visibility; however, contrast en-
hancement can be suboptimal in dogs with renal insuffi-
ciency.4
Ultrasonography allows more consistent visualization of
the kidneys, and does not require the use of intravenous
contrast media. Ultrasonographic renal volume measure-
ments have been useful in humans5,6 and more recently in
dogs,7 especially following renal transplantation. A parallel
planimetric area technique and a prolate ellipsoid method
have been used to estimate renal volume. In animals, the
From the Companion Animal Research Group, Département de Sci-
ences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal,
3200 rue Sicotte, C.P. 5000, Saint-Hyacinthe, Québec, Canada, J2S 7C6.
Address correspondence and reprint requests to Marc-André d’Anjou
at the above address. E-mail: marc-andre.danjou@umontreal.ca
Received October 13, 2006; accepted for publication February 15, 2007.
doi: 10.1111/j.1740-8261.2007.00274.x
other ultrasonographic methods.8 However, it is also the
most time consuming to perform and therefore can be im-
practical for routine clinical use. Although volume mea-
surements are more accurate for estimating renal size, there
is a statistically significant correlation between renal length
and body weight.3,9,10 However, a departure of the corre-
lation from linearity was observed in dogs of very low or
very high bodyweights.9 Normal ranges of renal length in
different body weight categories have been proposed,9 al-
though body fat, which can vary in dogs, was not taken
into consideration.
For routine use in veterinary medicine, the technique for
kidney size evaluation must not only be reliable, but must
also be quick and simple. As for ratios comparing renal
length with vertebrae in radiographs, relating ultrasono-
graphic renal measurements to some indicator of body size
could fulfill these conditions. Aortic diameter has been
previously used as a reliable landmark for ratio studies. It
can be used to quantify left atrial enlargement11 as well
as to evaluate portal vein diameter in portosystemic shunt
diagnosis.12
The objective of this study was to assess the utility of an
ultrasonographic ratio of renal length to aortic luminal
diameter in dogs with clinically normal renal function to
establish reference intervals that could be used in practice.
Materials and Methods
Part 1
Twenty client-owned dogs of various breeds and body
weights that were scheduled to undergo an abdominal
ultrasound examination were used to analyze intra- and
interobserver reproducibility. Dogs were in dorsal re-
cumbency and ventral abdominal hair was clipped.

434
Vol. 48, No. 5 KIDNEY-TO-AORTA RATIO IN DOGS 435

Fig. 1. (A). Schematic representation of measurement of the renal length and aortic diameter (Ao), the latter obtained just caudal to the level of the left renal
artery (RA). (B) The renal length is obtained after smooth rotation of the probe, while keeping the renal pelvis in the center, to reach maximal linear
measurement. After reviewing cineloop frames, the maximal luminal diameter of the aorta is measured on transverse (C) and longitudinal (B) planes.

Transducer-skin contact was achieved using standard cou-
pling gel. Real time ultrasonographic images were obtained
using a 5–8 MHz curvilinear electronic transducer. Each
kidney was evaluated with a subcostal and/or intercostal
ventrolateral approach and the maximal length of each
kidney was measured twice by two experienced sonograp-
hers (Fig. 1). To prevent slice obliquity and consequent
underestimation of maximal renal length, each measure
was obtained while smoothly twisting the probe, internally
and externally, and including the renal pelvis in the field of
view. The aortic luminal diameter was also measured twice
in both transverse and longitudinal planes (Fig. 1), just
caudal to the origin of the left renal artery. Measurements
were made from still images acquired at maximal luminal
diameter, after reviewing cineloop frames to account for
pulsation of the aorta. Measurement cursors were placed at
the margins of the lumen, excluding the vessel walls.
ATL HDI 5000, Advanced Technology Laboratories Inc., Bothell,
WA.
Statistical Analysis. Intra- and interobserver reproduc-
ibility and agreement were assessed using Bland and
Altman plots and appropriate statistics.13 Using this
approach, the similarity between measurements, either by
the same observer or by two different observers, can be
assessed from a clinical point of view. Briefly, the differ-
ence between measurements, the error, was plotted
against the mean of both measures. This way, good
agreement between measurements resulted in differences
closer to zero. Ninety-five percent confidence intervals
(95% CI) of the mean error were calculated and consid-
ered as limits of agreement. The range between limits of
agreement was expected to fall within
1 SD of the mean
of the measured structure.14 Wilcoxon’s signed rank tests
and Spearman’s correlations were also used as a com-
plementary analysis of the quality of agreement and to
pinpoint the existence of systematic bias in measure-
ments, respectively. A systematic bias was encountered
when the measurement error was related to the magni-
tude of the measured structure. A probability value
(Po0.05) was considered statistically significant. Data
were expressed as mean
standard deviation (SD).
436 MARESCHAL ET AL. 2007

Table 1. Assessment of Intraobserver Reproducibility

Difference Between Readings Readings

LoA (% of Mean
Structure Observer Mean
SD (cm) L-LoA (cm) U-LoA (cm) Range LoA (cm) Mean
SD (cm) Readings)
Left kidney 1 0.05
0.14 0.32 0.22 0.54 5.97
2.00 5.4 to 3.7%
2 0.05
0.22 0.49 0.39 0.88 5.99
1.97 8.2 to 6.5%
Right kidney 1 0.01
0.16 0.30 0.32 0.62 6.13
2.04 4.9 to 5.2%
2 0.06
0.24 0.42 0.53 0.94 6.09
2.02 6.9 to 8.7%
Aorta sagittal 1 0.00
0.04 0.08 0.09 0.16 0.85
0.29 9.4 to 10.6%
2 0.01
0.07 0.12 0.13 0.25 0.87
0.30 13.8 to 14.9%
Aorta transverse 1 0.01
0.04 0.09 0.08 0.18 0.83
0.30 10.8 to 9.6%
2 0.00
0.02 0.04 0.04 0.08 0.89
0.30 4.5 to 4.5%

SD, standard deviation; L-LoA, lower limit of agreement (95% confidence intervals); U-LoA, upper limit of agreement (95% confidence intervals);
LoA, limits of agreement.

Part 2 normality and constant residual variance. Normality for

Client-owned dogs presented for abdominal ultrasono-
graphy for nonrenal disease between May and November
2005 were studied. Dogs had ultrasonographically normal
kidneys; and the blood urea nitrogen and creatinine levels
were also normal; no proteinuria was detected; and urine
specific gravity was higher than 1.030. Dogs with immune-
mediated diseases, based on the presence of autoaggluti-
nation and spherocytosis on smear or based on a positive
Coombs test, were excluded. The maximal length of each
kidney and the maximal luminal diameter of the aorta in a
longitudinal plane were measured as described in the first
part of the study. With these values, three different ratios
were calculated for each dog: left renal length/aorta diam-
eter (LK/Ao), right renal length/aorta diameter (RK/Ao)
and mean renal length/aorta diameter (Km/Ao).
Statistical Analysis. Descriptive statistics such as mean,
median, range (minimum to maximum), SDs and 95% CI
of the mean were calculated.for the aorta diameter, kid-
ney length (right and left), kidney/aorta ratio (right and
left) and mean kidney/aorta ratio. A probability value
(Po0.05) was considered statistically significant. Rela-
tionship and association between aorta diameter and
kidney length were assessed using linear regression anal-
ysis and Pearson’s coefficient test, after ensuring residual
kidney/aorta ratio was evaluated using Shapiro–Wilk and
Anderson darling tests. The absolute length of the right
and left kidneys were finally compared using the paired
Student’s t-test and the effect of gender on Km/Ao ratio
was determined by a two sample Student’s t-test.
Results
Part 1
Intra- and interobserver reproducibility and agreement
were ensured using Bland and Altman plots and statistics.
The measurement errors were considered low while ranges
between limits of agreement fell within
1 SD of the av-
erage measurement (Tables 1 and 2). Despite this agree-
ment, the difference between inter-observer readings
(0.06
0.06 cm) was considered different from zero
(Po0.001) when the aorta was measured in the transverse
plane. As a precaution, this imaging plane was excluded for
the rest of the study. Also, a statistically significant sys-
tematic bias was found (P ¼ 0.029) for intraobserver re-
producibility in measuring the aortic luminal diameter in
the longitudinal plane. The degree of measurement error
increased as the mean aortic diameter increased. However,
the mean error was 0.00
0.04 cm, giving a range of
agreement of 0.16 cm (Table 1). This measurement error
was not considered to be clinically significant.

Table 2. Assessment of Interobserver Reproducibility

Difference Between Observers Readings

Structure Mean
SD (cm) L-LoA (cm) U-LoA (cm) Range LoA (cm) Mean
SD (cm) LoA (% of Mean Readings)
Left kidney 0.02
0.21 0.43 0.39 0.82 5.98
1.98 7.2 to 6.5%
Right kidney 0.03
0.17 0.30 0.36 0.69 6.11
2.02 5.1 to 6.2%
Aorta sagittal 0.02
0.06 0.14 0.11 0.25 0.86
0.29 16.3 to 12.8%
Aorta transverse 0.06
0.06 0.17 0.06 0.23 0.86
0.30 19.8 to 7.0%

SD, standard deviation; L-LoA, lower limit of agreement (95% confidence intervals); U-LoA, upper limit of agreement (95% confidence intervals);
LoA, limits of agreement.
Vol. 48, No. 5 KIDNEY-TO-AORTA RATIO IN DOGS 437

Part 2
Ninety-two adult dogs (45 males, 47 females) of various
breeds, ranging from 1 to 13 years of age (7.1
2.8 years)
and weighting between 1.5 and 65.3 kg (28.4
16.4 kg)
were studied. Of these, 22 were of small size breeds (esti-
mated lean bodyweight of o10 kg); 16 of medium size (10–
20 kg); and 54 of large size (more or equal to 20 kg).
Renal measurements were performed on both sides for
every dog (Table 3). The margins of the left kidney were
easier to assess compared with the cranial margin of the
right kidney, which was often not clearly outlined. The
more cranial, deep and often subcostal position of this
kidney, as well as the presence of overlying gastrointestinal
content explained this difference.
The mean length of the right kidney was not significantly
Fig. 2. A plot of renal length as a function of aortic luminal diameter,
different from that of the left kidney (P ¼ 0.774). In ad- with the regression line, in dogs with normal renal function. The regression
dition, as the aortic diameter was constant within each dog, equation is y ¼ 1.53 þ 5.44x. The Pearson’ correlation coefficient is 0.89 with
there was no statistically significant difference between LK/ a P-value of o0.001.

Ao and RK/Ao ratios. Furthermore, Km/Ao ratios did not

differ between male and female dogs (P ¼ 0.198).
There was a positive linear relationship between aorta
diameter vs. kidney length (Fig. 2), (Po0.001; Pearson’s
correlation coefficient ¼ 0.89).
Discussion
Reproducibility is required for meaningful clinical ap-
plication of any measurement method. We found that renal
length and aortic maximal luminal diameter can be mea-
sured consistently by experienced sonographers. Using a
longitudinal plane to measure aorta maximal luminal di-
ameter was more consistent between observers. This can
probably be explained by the greater difficulty in confi-
dently selecting a true perpendicular section of the aorta
with a transverse approach.
Although the cranial margin of the right kidney was not
clearly outlined in all dogs, the difference in absolute length
measurements and K/Ao ratios between the right and left
kidney were not statistically significant. Furthermore, ra-
tios were not different between male and female dogs.
Consequently, only one K/Ao ratio interval can be used for
either kidney, in male and female dogs, which is of prac-
tical value.
Based on 95% CI measured for K/Ao ratios, clinical
recommendations can be made. Renal size should be con-
sidered reduced if the K/Ao ratio is o5.5 and increased
when over 9.1. This interval is broad, consistent with pre-
vious studies in which substantial variation in renal length
among dogs of similar bodyweight was reported.3,9 Fur-
thermore, it must be remembered that a kidney can be
abnormal without a significant alteration in size.2 There-
fore, these ratios should only be used to indicate abnormal
renal size and as only one parameter in the ultrasono-
graphic evaluation of renal disease. Other clinical and ul-
trasonographic parameters should be considered to assess
renal function and architecture.
As opposed to a previous study that compared renal
length with bodyweight in dogs,9 these parameters were
intentionally not compared in our study. To understand
this, a prior canine echocardiographic study provides a
basis for comparison. M-mode measurements are based
on the existence of a linear relationship between these
M-mode measurements and body weight.15 However, the
relationship between the geometry of three-dimensional
objects follows an allometric equation as y ¼ axb, instead of
a linear equation as y ¼ ax þ b.15 y represents a measure

Table 3. Results of Ultrasonographic Measurements and Calculated K/Ao Ratio

Kidney Length Kidney/Aorta Ratio

Aorta Diameter (cm) Right (cm) Left (cm) Right (cm) Left (cm) Mean Kidney/Aorta Ratio
Number of dogs 92 92 92 92 92 92
Median 0.9 6.6 6.7 7.1 7.1 7.1
Mean
SD 0.9
0.3 6.4
1.5 6.4
1.5 7.3
1.0 7.3
0.9 7.3
0.9
95% CI 0.4–1.4 3.4–9.5 3.3–9.5 5.4–9.3 5.5–9.0 5.5–9.1
Range 0.3–1.6 3.1–11.0 2.8–10.8 5.5–9.7 5.6–9.6 5.5–9.4

SD, standard deviation; 95% CI, confidence intervals.

438 MARESCHAL ET AL.
(length, area or volume); x the bodyweight; a and b are
constants. The allometric equation becomes linear only
when bodyweight is compared with a volume (then b ¼ 1).
Consequently, the assessment of the kidney length based
on bodyweight would require a complicated formula that
would be more difficult to apply in a clinical setting.
Our study has some limitations. Although our method
of measurement is reproducible for experienced ultra-
sonographers, the level of experience required to reliably
obtain these values was not tested. However, we believe
that practitioners with basic training should be able to use
these ratios. Additionally, the effects of hydration or
systemic arterial pressure on aortic luminal diameter were
not assessed and could represent a significant variable in
dogs with renal disease. Aortic luminal diameter can also
vary significantly during the cardiac cycle, which could
affect the reliability of its measurement. This was taken
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