Doppler ultrasound of the kidneys: anatomy, techniques, and normal findings
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Doppler ultrasound of the kidneys: anatomy, techniques, and normal findings
- 1. Doppler ultrasound of the kidneys
- 2. Normal anatomy of the kidney • : Renal parenchyma cortex Renal sinus: arteries,veins, lymphatic, collecting system Renal hilum: Concave, renal sinus
- 3. Anatomy of renal arteries • RRA: Usually passes posterior to inferior vena cava • LRA: Usually courses posterior to left renal vein
- 4. Arterial blood supply to the Kidney Segmental artery Apical, upper, middle, lower, posterior Interlobular artery Between renal pyramids Glomerular arteriole Main renal artery Arcuate artery Between cortex & medulla
- 5. Left-sided IVC Normal anatomy of IVC Anomalous left-sided IVC
- 9. Indications of Renal Doppler Ultrasound
- 10. 1-Renal Artery Stenosis 2-Renal Artery Thrombosis 3-Renal Artery Emboli 4-Renal vein thrombosis 5-Aneurysm & Pseudo Aneurysm 6-Arterio-venous communications 7-Renal mass 8-Hypertension in Young age
- 11. Gray scale imaging first Kidneys renal length Echogenicity of renal cortex Thickness of renal cortex Masses hydronephrosis renal calculi Aorta Plaque – thrombus – dissection – aneurysm
- 12. 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)
- 13. Renal Dimensions Length: 9 – 14 cm (longitudinal section) Width: 4 – 6 cm (cross section) Depth: 4 – 6 cm (cross section) Appropriate renal volume 231 ± 50 ml Cortical thickness: 8 – 10 mm Parenchymal thickness: 14 – 18 mm
- 14. Classification of renal parenchymal echogenicity 4 types based of US appearance Hypoechoic compared to liver Isoechoic compared to liver Hyperechoic compared to liver Isoechoic to renal sinus Normal Normal Pathological Pathological Grade 0 Grade I Grade II Grade III
- 15. Kidney parenchyma compared to liver parenchyma Hypoechoic Isoechoic Hyperechoic
- 16. Congenital Normal Variant • Dromedary Hump • Fetal Lobulation • Prominent column of bertin • Junctional Parenchymal defect • Hypoechoic renal sinus
- 17. Dromedary hump Fetal lobulation 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
- 18. 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
- 19. Transverse scan with probe angulations Main renal arteries
- 20. Normal right renal artery Transverse gray scale image Right main renal artery Transverse color Doppler image Right main renal artery
- 21. Normal left renal artery Gray scale image Color Doppler image Proximal main left renal artery Proximal main left renal artery
- 22. Axial scan in left lateral decubitus Using right kidney as acoustic window Right main renal artery & vein Color Doppler USSchematic drawing
- 23. Axial scan in right lateral decubitus Using left kidney as acoustic window Schematic drawing Left main renal artery & vein Color Doppler US Zubarev AV. Eur Radiol 2001 ; 11 : 1902 – 1915.
- 24. Pulsed Doppler of renal veins Right renal vein Resembles pulsed Doppler of IVC Triphasic waveform Left renal vein Little modulation Wall artifact due to systolic peak
- 25. 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%
- 26. Angle of insonation Difficulty in case of tortuous or curved renal artery Correct angleIncorrect angle
- 27. 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
- 28. Normal segmental & interlobar renal arteries Normal segmental renal arteries (long arrows) Color Doppler image of the kidney Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475. Normal inter-lobar renal arteries (short arrows)
- 29. 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.
- 30. Normal pulse Doppler waveform Renal segmental artery • Sharp systolic upstroke • Low resistance waveform • Continuous forward diastolic flow
- 31. Early systolic notch Some normal waveforms have early systolic notch Measuring to point of PSV results in prolonged AT & AI Excellent negative predictive value of stenosis > 60%
- 32. Extrasystole Correct RI calculated in normal sinusoidal rhythm
- 33. 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
- 39. Why we want permanent everything in a temporary life.
Editor's Notes
- The normal adult kidney is bean shaped with a smooth convex contour anteriorly, posteriorly, andlaterally. Medially, the surface is concave and known as the renal hilum. The renal hilum is continuous with a central cavity called the renal sinus. The collecting system (renal pelvis) lies posterior to the renal vessels in the renal hilum.
- ● The right renal artery is longer than the left, and passes posterior to the IVC. ● The left renal artery has a more horizontal course to the kidney.
- Anomalous left-sided IVC from persistence of the embryological azygos vein.
- Discrepancy of more than 2 cm between the lengths of two kidneys is considered significant and needs further evaluation. The renal parenchyma is composed of cortex and medullary pyramids. The renal medullary pyramids are hypoechoic relative to the renal cortex and can be identified in most normal adults. The normal renal cortex has classically been described as being less echogenic than adjacent liver and spleen. Platt et al. evaluated 153 patients and found that 72% of patients with renal cortical echogenicity equal to that of the liver had normal renal function. If renal echogenicity greater than the liver were used as the criterion, both specificity and positive predictive value for abnormal renal function rose to 96% and 67%, respectively. However, sensitivity is poor-only 20%.
- Easily differentiated from renal mass: 1- similar echotexture to adjacent renal parenchyma on gray-scale ultrasound. 2- CFD and PD will demonstrate similar perfusion to that of adjacent renal parenchyma.