Doppler ultrasound of the kidneys

Samir Haffar M.D.

Assistant Professor of Internal Medicine
 Doppler US of the kidneys

• Normal anatomy of the kidney

• Normal US of the kidney
• Normal Doppler US of the kidney
• Indications of renal Doppler US
 Normal anatomy of the kidney

Renal parenchyma: cortex & medullary pyramids

Renal sinus: arteries, veins, lymphatics, collecting system, & fat
Renal hilum: Concave, in continuity with renal sinus
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
 Anatomy of renal arteries

RRA: Usually passes posterior to inferior vena cava

LRA: Usually courses posterior to left renal vein
Multiple renal arteries in 25% (inferior polar artery from aorta)
 Arterial blood supply to the Kidney

Main renal artery

Segmental artery
Apical, upper, middle, lower, posterior

Interlobular artery
Between renal pyramids

Arcuate artery
Between cortex & medulla

Glomerular arteriole

.Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004
 Left renal vein

• Longer than right renal vein

• Averages 85 mm in length (range: 60 – 110 mm)
• Joined by adrenal, gonadal, lumbar, & hemiazygous
veins before crossing the aorta
• Different types: Pre-aortic 80 – 95%
Retro-aortic 2 – 3%
Circum-aortic 7 – 9%

Sidhu R et al. Semin Ultrasound CT MRI 2009 ; 30 : 271 – 288.

 Variants of left renal vein

Retro-aortic LRV Circum-aortic LRV

Incidence: 2 – 3% Incidence: 7 – 9%

Sidhu R et al. Semin Ultrasound CT MRI 2009 ; 30 : 271 – 288.

 Left-sided IVC
Normal anatomy of IVC Anomalous left-sided IVC

Persistence of embryological AV

Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
 Doppler US of the kidneys

• Normal anatomy of the kidney

• Normal US of the kidney
• Normal Doppler US of the kidney
• Indications of renal Doppler US
 Gray scale imaging first

• Kidneys Maximum renal length

Echogenicity of renal cortex
Thickness of renal cortex
Masses – hydronephrosis – renal calculi
• AortaPlaque – thrombus – dissection – aneurysm
• Adrenal glands
 Normal kidney
Longitudinal section Cross section

Renal capsule: echogenic line

Renal parenchyma: outer cortex & inner medulla pyramid
Central sinus complex: high echogenicity (vessels, fat, fibrous tissue)

Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3 rd edition, 2005.
 Renal dimensions

• Length of normal kidney: 9 – 14 cm

Right kidney smaller than left kidney
• Discrepancy > 2 cm between two kidneys:
Considered significant & needs further evaluation
• Renal length between 8 – 9 cm
Correlated to patient’s phenotype particularly height
• Renal length < 8 cm definitely reduced
Should be attributed to chronic renal failure

.Fiorini F et al. J Ultrasound 2007 ; 10 : 161 – 167

Measurement of parenchymal & cortical thickness

Cortical thickness: Normal 8 – 10 mm

Parenchymal thickness: Normal 14 – 18 mm

Tuma J et al. European course book: Genitourinary ultrasound.

.European Foundation of Societies of Ultrasound in Medicine & Biology
 Renal volume
Length: 9 – 14 cm (longitudinal section)
Width: 4 – 6 cm (cross section)
Depth: 4 – 6 cm (cross section)
Ellipsoid formula: length . width . thickness . π/6

Adjusted to BMI
(V / BMI) . 25

Appropriate renal volume

231 ± 50 ml
Derchi LE et al. Acad Radiol 1994 ; 1 : 100 – 105.
Fiorini F et al. J Ultrasound 2007 ; 10 : 161 – 167.
Classification of renal parenchymal echogenicity

types based of US appearance 4

Grade 0 Hypoechoic compared to liver Normal
Grade I Isoechoic compared to liver Normal
Grade II Hyperechoic compared to liver Pathological
Grade III Isoechoic to renal sinus Pathological

Hricak H et al. Radiology 1982 ; 144 : 141 – 147.

Fiorini F et al. J Ultrasound 2007 ; 10 : 161 – 167.
Kidney parenchyma compared to liver parenchyma
Hypoechoic Isoechoic

Hyperechoic

Fiorini F et al. J Ultrasound 2007 ; 10 : 161 – 167.

 Congenital normal variants of kidney

• Dromedary hump
• Persistent fetal lobulation
• Prominent column of Bertin
• Junctional parenchymal defect
• Hypoechoic renal sinus

.Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41

 Dromedary hump
Common renal variation

Focal bulge on lateral border of left kidney

Result from adaptation of renal surface to adjacent spleen
Easily differentiated from renal mass by Doppler

.Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41

 Persistent fetal lobulation

Renal surface indentations between pyramids

May be single or multiple

.Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41

 Prominent column of Bertin (PCB)
Mistaken for intrarenal tumor

Continuity with renal cortex

Similar echo pattern as renal parenchyma
Similar vascular pattern by color & power Doppler
.Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41
 Junctional fusion defect
Mistaken for cortical scar or angiomyolipoma

Triangular hyperechoic structure Continuity with central

Antero-superior or postero-inferior sinus
surface of kidney by echogenic line
“inter-renicular septum”
.Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41
 Abdominal aorta

• Normal abdominal aorta 1.5 – 2.5 cm

• Ectatic aorta 2.5 – 3 cm

• Aortic aneurysm > 3 cm

• Annual growth of aneurysms 0.33 cm/year

between 4 & 5.5 cm

.Bhatt S et al. Ultrasound Clin 2008 ; 3 : 83 – 91 *

 Cross-section at adrenal glands
Compared to seagull, Y, or V letter

Y-shaped structures lying antero-medial to kidneys

Composed of body & medial & lateral “wing” or “limb”

Tuma J et al. European course book: Genitourinary ultrasound.

.European Foundation of Societies of Ultrasound in Medicine & Biology, 2011
 US of normal adrenal glands
Documented in 1980 1
Right adrenal gland Left adrenal gland

Transcostal scan in LLD Transverse scan of epigastrium

Between RLL, IVC & diaphragm Dorsal to pancreatic tail & SV

With modern equipment (high-resolution) & good training

US can image right gland in 99% & left gland in 70%1
1
Dietrich CF et al. Endoscopy 1997 ; 29 : 859 – 864.
2
Jenssen C et al. Ultraschall Med 2010 ; 31: 228 – 250.
 Normal adrenal gland / Inverted Y-shape
Coronal scan of right upper abdomen through MAL

Hypoechoic right adrenal gland

Horizontally inverted Y-shape

Wan YL. J Med Ultrasound 2007 ;15 : 213 – 227.

 Doppler US of the kidneys

• Normal anatomy of the kidney

• Normal US of the kidney
• Normal Doppler US of the kidney
• Indications of renal Doppler US
 Technical points

• Fasting for at least 6 hours before the exam

• Duration of the examination: 30 – 45 min
• Rare failure: Non-cooperant patient – Gas
• Intestinal preparation: not necessary

Operator-dependent technique
Slow learning curve
Most complex & difficult Doppler examination1

1
Jaeger KA & Uthoff H. Ultraschall Med 2010 ; 31 : 339 – 343.
 Sites for pulsed Doppler of renal arteries

Aorta
Ostium of main renal artery
Trunk of main renal artery
Hilum of kidney
Upper pole of kidney
Middle pole of kidney
Lower pole of kidney
 Transverse scan with probe angulations
Main renal arteries

Schäberle W. Ultrasonography in vascular diagnosis. Springer-Verlag, Berlin, 2 nd edition, 2011.

 Norma right renal artery

Transverse gray scale image Transverse color Doppler image

Right main renal artery Right main renal artery

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Gray scale alone without color Doppler
Patients with difficulty to hold breath
Gray scale image

Entire RRA well visualized

Color flash artifact from patient motion may obscure visualization
Better spatial resolution & and faster frame rate
Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.
 Norma left renal artery

Gray scale image Color Doppler image

Proximal main left renal artery Proximal main left renal artery

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 ‘‘banana peel’’ or “Isikoff” view
Longitudinal transhepatic view in Left lateral decubitus

Gray scale image Color Doppler image

Origins of right & left renal arteries Origins of right & left renal arteries

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

Isikoff MB et al. Am J Roentgenol 1980 ; 134 : 1177 – 1179.
 Normal right renal artery
Coronal images of IVC

RRA is the only vessel to course laterally under the IVC

Often slightly indents the IVC

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Two renal arteries or early branching?

Longitudinal view of IVC Transverse view of aorta

Two right renal arteries Early branching of RRA

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

Longitudinal scan in left lateral decubitus
Multiple renal arteries (25%)

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Two left renal arteries
Dominant left renal artery Accessory left renal artery

PSV: 90 cm/sec PSV: 60 cm/sec

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Axial scan in left lateral decubitus
Using right kidney as acoustic window
Schematic drawing Color Doppler US

Right main renal artery & vein

Meola M et al. J Ultrasound 2008 ; 11 : 55 – 73.

 Axial scan in right lateral decubitus
Using left kidney as acoustic window
Schematic drawing Color Doppler US

Left main renal artery & vein

Zubarev AV. Eur Radiol 2001 ; 11 : 1902 – 1915.

 Pre-caval right renal artery

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Pre-aortic left renal vein (80 – 95%)

Reduction in diameter in pre-aortic segment to IVC

with physiologic acceleration

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Left renal vein variants

Retro-aortic LRV (2 – 3%) Circum-aortic LRV (7 – 9%)

Pre & retro-aortic LRV

Sidhu R et al. Semin Ultrasound CT MRI 2009 ; 30 : 271 – 288.

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.
Color Doppler of RRV & retro-hepatic IVC
Righ renal vein Inferior vena cava

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Pulsed Doppler of renal veins
Left renal vein Right renal vein

Little modulation Resembles pulsed Doppler of IVC

Wall artifact due to systolic peak Triphasic waveform

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Limits in visualization of main renal arteries
•Obesity
•Overlying bowel gas
•Dyspnea
•Shadowing from arterial calcifications
•Cardiac arrhythmias
•Poor angle of Doppler insonation
•Accessory renal arteries (small size)
Expert sonographers detect 80 – 90% of main RA
CEUS improves success rate to 95%
Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.
 Angle of insonation
Difficulty in case of tortuous or curved renal artery

Incorrect angle Correct angle

Schäberle W. Ultrasonography in vascular diagnosis.

Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
 Adjustment of Doppler control
Low flow settings

• Lowest pulse repetition frequency without aliasing

• Small color box
• Greatest gain without background noise
• Lowest wall filter
• High color priority
Normal segmental & interlobar renal arteries

Color Doppler image of the kidney

Normal segmental renal arteries (long arrows)

Normal inter-lobar renal arteries (short arrows)

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Study of intra-renal arteries
Perfusion study / Low PRF

Cortical perfusion
Tumoral vascularization

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Study of intra-renal arteries
Morpho-hemodynamic study

Intermediate PRF
Arterio-venous fistula
Pseudo-aneurysm
High PRF
Renal stones
Vascular calcifications

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Normal kidney
Power Doppler

Increases sensitivity to low flow

Less angle-dependent
Good visualization of the entire renal vascular tree

Zubarev AV. Eur Radiol 2001 ; 11 : 1902 – 1915.

Normal pulse Doppler waveform
Renal segmental artery

Sharp systolic upstroke

Low resistance waveform
Continuous forward diastolic flow
 Pourcelot’s resistive index

RI S – ED / S
Normal 50 – 70 %
Abnormal > 80 %
 Accleration time (AT)
or Rise time (RT)

• Length of time in sec from

onset of systole to peak systole

• Normal value: < 0.07 second

 Acceleration Index (AI)
Systolic upslope/transducer frequency

X (KHz)
AI =
Probe frequency (MHz)

Normal value: > 3.5 m/s2

Measurement of PSV

Early systolic peak

Biphasic with late systolic peak

Monophasic with late systolic peak

Am J Roentgenol – Dec 1995

 Early systolic notch

Some normal waveforms have early systolic notch

1. Measuring to point of PSV results in prolonged AT & AI
2. Excellent negative predictive value of stenosis > 60%

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Extrasystole

Correct RI calculated in normal sinusoidal rhythm

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Spectral Doppler of renal arteries
Normal values

• PSV < 180 cm/sec

• Renal Aortic Ratio (RAR) <3
• Resistive index (RI) < 0.70
• ∆ RI (right – left) < 0.05
• Acceleration Time (AT) < 0.07 sec
• Acceleration Index (AI) > 3.5 m/s2
 Doppler US of the kidneys

• Normal anatomy of the kidney

• Normal US of the kidney
• Normal Doppler US of the kidney
• Indications of renal Doppler ultrasound
 Pheochromocytoma
Uncommon – 1 % of patients with hypertension

“rules of 10” 2

10% Extra-adrenal
[paraganglioma]
10% of them extra-abdominal
10% Malignant
10 % Multiple masses
Highly vascularized
right pheochromocytoma

1
Jenssen C et al. Ultraschall Med 2010 ; 31: 228 – 250.
2
Wan YL et al. J Med Ultrasound 2007 ; 15 : 213 – 227.
 Conn’s sydrome / adrenal hyperplasia

Micronodular cortical hyperplasia of right adrenal gland

Structure measuring approximately 5 mm
& isoechoic to adrenal cortex

Jenssen C et al. Ultraschall Med 2010 ; 31: 228 – 250.

 Indications of renal Doppler ultrasound

 Renal artery stenosis

 Renal artery thrombosis & emboli
 Renal vein thrombosis
 Aneurysm & pseudo-aneurysm
 Arterio-venous communications
 Nutcracker syndrome
 Renal mass
 Miscellaneous indications
 Renal artery stenosis
1 – 5% of hypertensive population
• Atherosclerosis
of cases % 95 >
• Fibromuscular dysplasia (FMD)
• Dissection
• Embolization
• Aortic coarctation
• Renal Artery Aneurysm
• Arteritis
• Congenital
• Neurofibromatosis
• Irradiation
 Renal artery stenosis

Atherosclerosis FMD
> 90% < 10%

Age After age of 50 Young

Gender More common in males More common in females

Location Proximal 1 cm of main RA Middle of renal artery

Branching points Others (carotids)

Post-stenotic Rare Frequent

dilatation
 Clinical risk factors for renovascular HTN

• Abrupt onset of severe HTN: diastolic >120 mm Hg

• Accelerated or malignant HTN: grade III or IV retinopathy
• HTN refractory to appropriate three-drug regimen
• Onset of hypertension before age 30 or after age 60
• HTN with rapidly progressive renal failure
• Renal failure that develops in response to ACE inhibitor
• HTN associated with upper abdominal bruit
• Episodes of recurrent severe HTN & pulmonary edema

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Renal artery stenosis
Direct signs Indirect signs

Focal color aliasing AT > 0.07 sec

Color bruit AI < 3 m/s2
Turbulence Δ RI (right – left) > 5 %
PSV > 180 cm/sec
Renal Aortic Ratio > 3.5
Significant stenosis Severe stenosis
(50 – 85% diameter reduction) (> 85 % diameter reduction)
Sensitivity: 79 – 91% Sensitivity: 95%
Specificity: 73 – 97% Specificity: 97%
 Renal artery stenosis / Direct criteria
Non-significant stenosis (< 50% diameter stenosis)
Color Doppler US Power Doppler US

Plaque in anterior wall of LRA

Better visualization of plaque
PSV: 148 cm/sec

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Renal artery stenosis / Direct criteria

Aliasing in left renal artery PSV: 275 cm/sec

High-grade stenosis
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
 Renal artery stenosis / First Generation CEUS

Baseline color Doppler IV contrast agent Pulse Doppler image

RRA not identified RRA visualized PSV > 300 cm/s

Aliasing of SMA origin Focal color aliasing Severe stenosis of RRA

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Renal artery stenosis / Direct criteria

Aliasing in left renal artery PSV: 293 cm/sec – RI : 0.91

Retro-aortic course of LRV Controversial indication of PTA2

1
Schäberle W. Ultrasonography in vascular diagnosis. Springer-Verlag, Berlin, 2 nd edition, 2011.
2
Jaeger KA et al. Ultraschall in Med 2007 ; 28 : 28 – 31.
 Creatinine clearance after correction of RAS
according to RI before revascularization

131 pts with unilateral or bilateral RAS > 50 % of luminal diameter

Renal angioplasty or surgery

Radermacher J et al. N Engl J Med 2001 ; 344 : 410 – 417.

 Renal artery stenosis / Renal Aortic Ratio
Small right kidney (8.4 cm) PSV (aorta): 102 cm/s

PSV (RRA): 465 cm/s High grade stenosis of RRA

RAR: 4.5

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Renal artery stenosis / Indirect criteria
Right renal hilum Left renal hilum

PSV: 125 cm/sec PSV: 85.7 cm/s

EDV: 58.1 cm/s EDV: 47.2 cm/s
RI: 0.75 RI: 0.64
Δ RI (right – left) > 0.05 → RA stenosis in side of lower RI
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin, 2nd edition, 2011.
Renal artery stenosis / Tardus-Parvus wave
Severe stenosis (> 85 % diameter reduction)

Tardus: Longer rise time

Parvus: Low PSV

Freeman SJ. Ultrasound 2004 ; 12 : 69 – 74.

 Tardus-Parvus wave

• Mimics Abdominal coarctation

William syndrome
Aortic/mitral valve disease
Left ventricle dysfunction
CV medications: after-load reducers
• Exaggerating 25 mg captopril 1 hour before exam
• Minimizing Age – HTN – DM (vessel compliance)

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

Abdominal aortic aneurysm & renal arteries

Aneurysm arises below origin of both renal arteries

.Zubarev VZ. Eur Radiol 2001 ; 11 : 1902 – 1915

 Fibromuscular dysplasia
No parallelism of RRA walls Moniliform aspect of RRA

PSV 250 cm/sec Typical FMD in middle third of RRA

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Etiologies of renal artery dissection
Stenotic or occlusive lesion

• Atherosclerosis
• Fibromuscular dysplasia
• Extension of aortic dissection
• Marfan syndrome & Ehlers-Danlos syndrome
• Trauma & iatrogenic causes
• Idiopathic

Sidhu R et al. Semin Ultrasound CT MRI 2009 ; 30 : 271 – 288.

 Renal artery dissection
Flank pain & hematuria – Stenotic or occlusive lesion

Interruption of LRA « bec de flûte » Occlusion of LRA at its origin

Associated thrombosis of LRV Complete necrosis of LK

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Coarctation of abdominal aorta
Severe hypertension in a 6-year-old boy

Bilateral & symmetric Sagital view of aorta

tardus parvus waveform Severe narrowing at level of CA & SMA

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Guidelines for diagnosis of RAS

• Recommended as screening test

Duplex US followed by
CT angiography (except RF) & MR angiography
• Not recommended as screening test
Captopril renal scintigraphy
Plasma renin activity
Captopril test
Selective renal vein renin measurements

Hirsch AT et al. J Am Coll Cardiol 2006 ; 47 : 1239 – 1312.

 Indications of renal Doppler ultrasound

 Renal artery stenosis

 Renal artery thrombosis & emboli
 Renal vein thrombosis
 Aneurysm & pseudo-aneurysm
 Arterio-venous communications
 Nutcracker syndrome
 Renal mass
 Miscellaneous indications
 Renal artery thrombosis

• Causes Embolism: most common

Thrombosis – trauma – hypercoagulable state
• Symptoms Acute flank pain + hematuria
• Impression Renal stone
Leaking abdominal aortic aneurysm
• Doppler US Normal side: normal arterial & venous flow
Affected side: no arterial flow – venous flow
 Renal artery thrombosis / Complete
Power Doppler US Power Doppler US more medially

Flow in iliac artery

Absence of flow within kidney
& proximal anastomotic artery

Irshad A et al. Semin Ultrasound CT MRI 2009 ; 30 : 298 – 314.

 Renal artery thrombosis / Partial
Color Doppler US Pulsed Doppler US

Slender flow in main renal artery Low velocity: PSV 40 cm/s

Low resistance: RI 0.5

Caia S et al. Clinical Imaging 2008 ; 32 : 367 – 371.

 Renal artery embolism
No blood flow in upper pole Normal blood flow in lower pole

Low PSV in main renal artery

Caia S et al. Clinical Imaging 2008 ; 32 : 367 – 371.

 Indications of renal Doppler ultrasound

 Renal artery stenosis

 Renal artery thrombosis & emboli
 Renal vein thrombosis
 Aneurysm & pseudo-aneurysm
 Arterio-venous communications
 Nutcracker syndrome
 Renal mass
 Miscellaneous indications
 Doppler US in acute renal vein thrombosis
Acute flank pain & hematuria

• High RI in intra-renal arteries

Reversed flow in diastole

• Absence of flow in intra-renal veins

• Enlarged main renal vein with no flow

 Acute renal vein thrombosis
LRV more commonly involved (longer length)

Absence of color signal Reversed diastolic flow in

in main right renal vein main renal artery

Kraft JK.& Brandão LR. Pediatr Radiol 2011 ; 41 : 299 – 307.

 Acute renal vein thrombosis / Poor outcome

• Reduced perfusion at diagnosis

• Subcapsular fluid collections
• Profoundly hypoechoic & irregular renal pyramids
• Patchy cortical echotexture
Likely reflecting cortical infarction & hemorrhage

Kraft JK.& Brandão LR. Pediatr Radiol 2011 ; 41 : 299 – 307.

 Acute renal vein thrombosis / Poor outcome
Right kidney Left kidney

Severely decreased renal perfusion Normal perfusion for comparison

Kraft JK.& Brandão LR. Pediatr Radiol 2011 ; 41 : 299 – 307.

Acute renal vein thrombosis / Poor outcome

Subcapsular fluid Hypoechoic & irregular pyramids

collections Patchy hypoechoic areas in cortex

Kraft JK.& Brandão LR. Pediatr Radiol 2011 ; 41 : 299 – 307.

 Chronic renal vein thrombosis / Collateral flow

No flow in main right renal vein Capsular collateral veins

Collateral flow clearly seen Linear calcifications in parenchyma

Zubarev VZ. Eur Radiol 2001 ; 11 : 1902 – 1915.

Kraft JK.& Brandão LR. Pediatr Radiol 2011 ; 41 : 299 – 307.
 Indications of renal Doppler ultrasound

 Renal artery stenosis

 Renal artery thrombosis & emboli
 Renal vein thrombosis
 Aneurysm & pseudo-aneurysm
 Arterio-venous communications
 Nutcracker syndrome
 Renal mass
 Miscellaneous indications
 Renal artery aneurysms
Extraparenchymal in 90% of cases

• Causes Atherosclerosis – FMD

Collagen deficiencies – Phacomatosis
• Gender More common in females
• Age Young patients
• Location Main renal artery or at bifurcation
• Wall Thin (risk of rupture)
• Treatment > 2.5 cm in diameter
Surgery (nephrectomy – kidney-sparing)
 Aneurysm of left renal artery
Gray-scale US Color Doppler US

Angiography

Gao J et al. Clinical Imaging 2006 ; 30 ; 140 – 142.

 Micro-aneurysms
Contraindication of renal biopsy (bleeding)

• Location Distal branches of cortex

Segmental arteries rarely
• Size 1 mm, 2-3 mm rarely
• Cause PAN (micoaneurysms in 100%)
• Clinic Fever – Abdominal pain – Hematuria – RF
• Diagnosis Arteriography – Not visible by Doppler

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Renal pseudo-aneurysm

• Causes Iatrogenic (percutaneous procedure) – Trauma

• Incidence Unknown
• Clinic Silent Small & resolve uneventfully
Hematuria Communicate with collecting syst
Bleeding Rupture in perirenal space
• Rx Small Monitoring until they resolve
Large Transcatheter embolization
 Pseudo-aneurysm

Sampling at neck To-and-fro waveform

“To” Systole
“Fro” Diastole
 Renal pseudo-aneurysm

Cystic lesion in middle of RK “to and fro waveform”

Bi-directional flow within neck of the lesion
“yin -yang pattern”

Rashid M et al. Emerg Radiol 2007 ; 14 : 257 – 260.

 Indications of renal Doppler ultrasound

 Renal artery stenosis

 Renal artery thrombosis & emboli
 Renal vein thrombosis
 Aneurysm & pseudo-aneurysm
 Arterio-venous communications
 Nutcracker syndrome
 Renal mass
 Miscellaneous indications
 Arterio-venous communication
Direct communication from artery to vein without capillary bed

• Congenital A-V malformation

25% Multiple large arterial feeding vessels
Numerous A-V communications
• Acquired A-V fistula
75% Single communication of artery & vein
0.3 – 4 % after kidney biopsy

Sidhu R et al. Semin Ultrasound CT MRI 2009 ; 30 : 271 – 288.

 A-V malformation
Hydronephrosis or cyst Aneurismal dialatation with
with calcified wall peri-vascular artifact

Low resistance arterial flow A-V malformation

Arterialized venous flow with pseudo-aneurismal dilatation

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 A-V fistula
First described in 1962 1
• Cause Iatrogenic (percutaneous procedure) –Trauma
• Clinic Asymptomatic (80%)
Gross hematuria – High output cardiac failure
Thrombo-embolic episodes – RF – HTN
• Evolution Most regress spontaneously in 6 months
Some progress to life-threatening complication
• Rx Asymptomatic: follow-up by Doppler
Symptomatic: embolization

Routine post-biopsy Doppler US & 6 months later

1
Fernstrom I et al. J Urol 1962 ; 88 : 709.
2
J Clin Ultrasound 2008 ; 36 : 377 – 380.
 Arterio-venous fistula

Color Doppler US / High PRF Feeding artery & draining vein

Feeding artery

Perivascular artifact in inferior pole Low resistance arterial flow

“confetti phenomenon” Arterialized venous flow

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Indications of renal Doppler ultrasound

 Renal artery stenosis

 Renal artery thrombosis & emboli
 Renal vein thrombosis
 Aneurysm & pseudo-aneurysm
 Arterio-venous communications
 Nutcracker syndrome
 Renal mass
 Miscellaneous indications
 Doppler US in nutcracker syndrome

Ratio of A-P diameter of LRV

Hilar portion & aorto-mesenteric portion
Cut-off value in supine position 3.8
Cut-off value in upright position 5.5
Ratio of peak velocities of LRV
Aorto-mesenteric portion & hilar portion
Cut-off value in supine position 4.2
Cut-off value in upright position 5.1

Fitoz S et al. J Ultrasound Med 2007 ; 26 : 573.

 Nutcracker syndrome / Ratio of A-P diameter
Oblique transverse sonograms
Supine position Upright position

Hilar portion: 25 mm Hilar portion: 24 mm

Aorto-mesenteric portion: 2mm Aorto-mesenteric portion: 2mm
Ratio: 12.5 Ratio: 12

Peker A et al. J Clin Ultrasound 2011 ; 39 : 418 – 421.

Nutcracker syndrome / Ratio of peak velocities

LRV between aorta & SMA LRV near hilum

Peak velocity: 99.7 cm/sec Peak velocity: 19.9 cm/sec

Peak velocity ratio: 6

Cho BS et al. Nephrol Dial Transplant 2001 ; 16 : 1620 – 1625.

 Nutcracker syndrome / SMA angle
Supine position Upright position
33° 14 °

Cut-off value
41° in supine position – 21° in upright position

Peker A et al. J Clin Ultrasound 2011 ; 39 : 418 – 421.

 Indications of renal Doppler ultrasound

 Renal artery stenosis

 Renal artery thrombosis & emboli
 Renal vein thrombosis
 Aneurysm & pseudo-aneurysm
 Arterio-venous communications
 Nutcracker syndrome
 Renal mass
 Miscellaneous indications
 Doppler in renal Mass
Limited role compared to CT

• Pseudo-tumors Prominent column of Bertin

Persistent fetal lobulation
Dromedary hung
• Renal tumors Tumoral vascularization
CEUS: solid or cystic mass
• Venous invasion Renal veins
IVC

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Prominent column of Bertin (PCB)
Mistaken for intra-renal tumor

Prominent column of Bertin Normal interlobular arteries

or mass at periphery of PCB

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Vascularization of renal tumors

Jinzaki’s classification
Pattern 1 Intratumoral focal vessels Angiomyolipoma
Pattern 2 Penetrating vessels Angiomyolipoma
Pattern 3 Peripheral vessels Carcinoma
Pattern 4 Penetrating & peripheral Carcinoma

Jinzaki M et al. Radiology 1998 ; 209 : 543 – 550.

 Vascularization of renal tumors
Pattern 3 Pattern 4

Peripheral vessels Penetrating & peripheral vessels

Carcinoma Carcinoma

Jinzaki M et al. Radiology 1998 ; 209 : 543 – 550.

 Solid renal mass / CEUS
Gray-scale US CEUS / 34 sec MSCT / arterial phase

Subtle deformation
Hypervascular lesion Hypervascular lesion
of renal contour
Clear renal cell tumor at surgery

Setola SV et al. Abdom Imaging 2007 ; 32 : 21 – 28.

 Bosniak renal cyst classification
Category CT features Significance
I Thin wall, water density & does not enhanced Benign
No septa, calcification, or solid component
II Thin septa with “perceived” enhancement Benign
Fine or slightly thick calcification
High attenuation non-enhancing cyst < 3 cm
IIF Thick regular septa with “perceived” Likely benign
enhancement Follow-up
Thick regular wall with “perceived” enhancement
Thick, nodular, & irregular calcification
High attenuation non-enhancing cyst > 3 cm
III Thick smooth or irregular septa
Some benign
Thick smooth or irregular wall
Some malignant
With measurable enhancement
IV Criteria of category III Malignant
Enhancing mass independent of wall or septa Cystic carcinoma

Israel GM & Bosniak MA. Urology 2005 ; 66 : 484 – 488.

 Cystic renal mass / CEUS
CECT scan CEUS

Thin-walled cyst
Enhancing mural nodule within cyst
No septa or solid component
Bosniak category IV
Bosniak category I
Renal cell carcinoma after partial nephrectomy
Park BK et al. Eur J Radiol 2007 ; 61 : 310 – 314.
 Invasion of IVC in RCC
Color Doppler US Power Doppler US

Localization of upper extremity Tumoral vascularization

of thrombus of thrombus

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Indications of renal Doppler ultrasound

 Renal artery stenosis

 Renal artery thrombosis & emboli
 Renal vein thrombosis
 Aneurysm & pseudo-aneurysm
 Arterio-venous communications
 Nutcracker syndrome
 Renal mass
 Miscellaneous indications
 Miscellaneous indications

• Nephropathies
• Kidney stones
• Hydronephrosis
• Uretero-pelvic junction obstruction
• Fraley syndrome (Upper calix syndrome)
 Renal Doppler in nephropathies

Elevated RI Normal RI
• Acute tubular necrosis Glomerulo-nephritis
• Tubulo-interstitial nephropathy (↑ RI in end stage disease)
• Micro-angiopathy
• Nephro-angiosclerosis
• Diabetic nephropathy
 Diabetic nephropathy

Increased resistive index: 0.89

Renal insufficiency

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Kidney stone / Twinkling artifact
High PRF & gain just below artifact limit

Large stone causing Twinkling sign from large stone

hydronephrosis Presence of small stone
Presence of posterior shadowing
Useful for evaluation of small kidney stones

.Tchelepi H et al. Am J Roentgenol 2009 ; 192 : 11 – 18

 Hydronephrosis

Hydronephrosis of right UPJ RI of RK: 0.65 RI of LK: 0.45

Δ RI (right – left) > 0.05
Sensibility: 10 – 40%, Specificity > 80%
Obstruction without dilatation
Indications Dilatation without obstruction
Hydronephrosis in pregnancy
Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.
 Renal colic in pregnancy
Physiological hydronephrosis or stone?

Retrospective study of 262 patients (2 local hospitals)

Data on clinical presentation, imaging, & interventions

Clinical & laboratory features unhelpful to predict stone
Left-sided colic more likely to indicate stone
Improved accuracy of Doppler in predicting stone (55 – 72%):
Elevated resistive index
Absence of urinary jet

.Andreoiu M et al. Urology 2009 ; 74 : 757 – 761

 Urinary jet

Obstructed ureter if no jet seen after 15 min of observation

Presence of jet do not exclude incomplete obstruction

Tuma J et al. European course book: Genitourinary ultrasound.

.European Foundation of Societies of Ultrasound in Medicine & Biology, 2011
 Uretero-pelvic junction obstruction
Most common cause of UT obstruction in children

Multiples proposed factors

Delayed recanalization of fetal ureter
Abnormal development of ureteral muscle
Abnormal ureteral peristalsis
Aberrant vessels or bands

Bilateral in 25%

Sivit CJ. Ultrasound Clin 2006 ; 1 : 67 – 75.

 Uretero-pelvic junction obstruction

Hilar artery seen in 30 – 45% of patients

Crossing vessel usually located anterior to UPJ obstruction

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

Sidhu R et al. Semin Ultrasound CT MRI 2009 ; 30 : 271 – 288.
 Fraley syndrome / Upper calyx syndrome
Vascular compression of superior calyx
IV pyelography Color Doppler US

Superior calyx obstruction Segmental artery crossing

due to extrinsic compression the dilated calyx
CT Angiography before tt: polar nephrectomy – reimplantation
Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.
 References

EFSUMB – 2011 Springer-Verlag – 2011

Hélénon O et al. EMC-Radiologie

2005 ; 2 : 367 – 412.
Thank You