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Basics of Pediatric Renal UltrasoundXVIII International Ultrasound Course
Mexican Society of Radiology and Imaging
Jennifer Lynn Nicholas, MD, MHA
Assistant Professor
Washington University School of MedicineSeptember X, 2018
Anatomy of a Normal Kidney
Anatomy of a Normal Kidney
source: www.hopkinsmedicine.com
Anatomy of a Normal Kidney
source: www.hopkinsmedicine.com
Anatomy of a Normal Kidney
source: www.hopkinsmedicine.com
Anatomy of a Normal Kidney
source: www.hopkinsmedicine.com
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Normal Size of Kidneys in Children
Han, B.K. and D.S. Babcock, Sonographic measurements and appearance of normal kidneys in children. AJR Am J Roentgenol, 1985. 145(3): p. 611-6.
Kadioglu, A., Renal measurements, including length, parenchymal thickness, and medullary pyramid thickness, in healthy children: what are the normative ultrasound values? AJR Am J Roentgenol, 2010. 194(2): p. 509-15.
Normal Size of Kidneys in Children
Han, B.K. and D.S. Babcock, Sonographic measurements and appearance of normal kidneys in children. AJR Am J Roentgenol, 1985. 145(3): p. 611-6.
RIGHT KIDNEY = 8.1 CM LEFT KIDNEY = 7.8 CM
3 YEARS OF AGE
Normal Size of Kidneys in Children
Han, B.K. and D.S. Babcock, Sonographic measurements and appearance of normal kidneys in children. AJR Am J Roentgenol, 1985. 145(3): p. 611-6.
RIGHT KIDNEY = 8.1 CM LEFT KIDNEY = 7.8 CM
Normal Size of Kidneys in Children
HEIGHT = 97 CM
Han, B.K. and D.S. Babcock, Sonographic measurements and appearance of normal kidneys in children. AJR Am J Roentgenol, 1985. 145(3): p. 611-6.
Normal Size of Kidneys in Children
WEIGHT = 14 KG
RIGHT KIDNEY = 8.1 CM LEFT KIDNEY = 7.8 CM
Han, B.K. and D.S. Babcock, Sonographic measurements and appearance of normal kidneys in children. AJR Am J Roentgenol, 1985. 145(3): p. 611-6.
Normal Size of Kidneys in Children
BSA= 6.1 cm^2
RIGHT KIDNEY = 8.1 CM LEFT KIDNEY = 7.8 CM
Standard Ultrasound Exam
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
Standard Ultrasound Exam
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
LEFT KIDNEY: The left kidney measures 7.8 cm, which is normal in length for the patient’s age, height, weight, and body surface area.
Standard Ultrasound Exam
Standard Ultrasound Exam
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
LEFT KIDNEY: The left kidney measures 7.8 cm, which is normal in length for the patient’s age, height, weight, and body surface area.
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
The right kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
LEFT KIDNEY: The left kidney measures 7.8 cm, which is normal in length for the patient’s age, height, weight, and body surface area.
Standard Ultrasound Exam
Standard Ultrasound Exam
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
The right kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
LEFT KIDNEY: The left kidney measures 7.8 cm, which is normal in length for the patient’s age, height, weight, and body surface area.
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
The right kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
LEFT KIDNEY: The left kidney measures 7.8 cm, which is normal in length for the patient’s age, height, weight, and body surface area.
The left kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
The right kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
LEFT KIDNEY: The left kidney measures 7.8 cm, which is normal in length for the patient’s age, height, weight, and body surface area.
The left kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
The right kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
There is no collecting system dilation.
LEFT KIDNEY: The left kidney measures 7.8 cm, which is normal in length for the patient’s age, height, weight, and body surface area.
The left kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
The right kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
There is no collecting system dilation.
LEFT KIDNEY: The left kidney measures 7.8 cm, which is normal in length for the patient’s age, height, weight, and body surface area.
The left kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
The right kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
There is no collecting system dilation.
LEFT KIDNEY: The left kidney measures 7.8 cm, which is normal in length for the patient’s age, height, weight, and body surface area.
The left kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
There is no collecting system dilation.
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Standard Ultrasound Exam
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
The right kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
There is no collecting system dilation.
LEFT KIDNEY: The left kidney measures 7.8 cm, which is normal in length for the patient’s age, height, weight, and body surface area.
The left kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
There is no collecting system dilation.
BLADDER: The urinary bladder is only distended to a volume of 28 mL, but is grossly normal.
Report for Normal Renal Ultrasound
DATE: 3/24/2014
CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.
EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.
COMPARISON: None.
FINDINGS:
RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.
The right kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
There is no collecting system dilation.
LEFT KIDNEY: The left kidney measures 7.8 cm, which is normal in length for the patient’s age, height, weight, and body surface area.
The left kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.
There is no collecting system dilation.
BLADDER: The urinary bladder is only distended to a volume of 28 mL, but is grossly normal. Neither ureter was visualized.
IMPRESSION: Normal sonographic appearance of the kidneys and bladder.
Report with Abnormal Findings
RIGHT KIDNEY = 7.5 CM LEFT KIDNEY = 7.4 CM
Han, B.K. and D.S. Babcock, Sonographic measurements and appearance of normal kidneys in children. AJR Am J Roentgenol, 1985. 145(3): p. 611-6.
RIGHT KIDNEY = 7.5 CM LEFT KIDNEY = 7.4 CM
NEWBORN
Normal Size of Kidneys in Children
Case One
RIGHT KIDNEY = 7.5 CM, which is more than two standard deviations above normal
LEFT KIDNEY = 7.4 CM, which is more than two standard deviations above normal
Normal position. Bulbous contour. Increased echogenicity. Loss of corticomedullary differentiation. Multiple cystic structures throughout the parenchyma. The collecting system is not dilated.
Normal position. Bulbous contour. Increased echogenicity. Loss of corticomedullary differentiationMultiple cystic structures throughout the parenchyma. The renal pelvis and a few central calyces are visualized.
Newborn with oligouria
Case One
RIGHT KIDNEY = 7.5 CM, which is more than two standard deviations above normal
LEFT KIDNEY = 7.4 CM, which is more than two standard deviations above normal
Normal position. Bulbous contour. Increased echogenicity. Loss of corticomedullary differentiation. Multiple cystic structures throughout the parenchyma. The collecting system is not dilated.
Normal position. Bulbous contour. Increased echogenicity. Loss of corticomedullary differentiationMultiple cystic structures throughout the parenchyma. The renal pelvis and a few central calyces are visualized.
Newborn with oligouria
AUTOSOMAL RECESSIVE POLYCYSTIC KIDNEY DISEASE
Case One
AUTOSOMAL RECESSIVE POLYCYSTIC KIDNEY DISEASE
“Hydronephrosis”
How would you describe these kidneys?
• Hydronephrosis
• Pelvocaliectasis
• Pelviectasis
• Pyelectasis
• Mild/Moderate/Severe
How would you describe these kidneys?
Antenatal Urinary Tract Dilation
Classification Systems
• Urinary tract dilatation in utero: Classification and clinical applications, Radiology 1986, Grignon et al.– Morphologic classification system– Grade 1
• APRPD <10 mm, normal
– Grade 2• Intermediate hydronephrosis, post-natal urology surgery ½ the time
– Grade 3• Intermediate hydronephrosis, post-natal urology surgery ½ the time
– Grade 4 • Moderate dilatation of the calyces, easily identified renal cortex,
surgery required
– Grade 5• Severe dilatation of the calyces, with atrophic cortex, surgery required
Classification Systems
SFU grading system
Timberlake MD, Herndon CD. Mild to moderate postnatal hydronephrosis--grading systems and management. Nat Rev Urol. 2013 Nov; 10(11):649-56
Classification Systems
Urinary Tract Dilation
Consensus on antenatal and postnatal urinary tract dilation (UTD)
1) unified description of upper tract dilation (pre and post natal)
2) a standardized scheme for the perinatal evaluation of these patients based in sonographic criteria
Classification system looks at
1) Anterior-posterior renal pelvic diameter (APRPD)
2) Calyceal dilation
3) Renal parenchymal thickness
4) Renal parenchymal appearance
5) Bladder abnormalities
6) Ureteral abnormalities
“A” denotes antenatal and “P” denotes postnatal
Consensus on antenatal and postnatal urinary tract dilation (UTD)
– Not designed as definitive final classification system
–Will need to be validated and/or modified with clinical experience and up to date evidence-based research
– Designed to be used in cases of isolated UT dilation
• not for solitary, ectopic, multicystic dysplastic kidneys (MCDK) or other cystic diseases of the kidney
• Not for post-surgical evaluation
Consensus on UTD Recommendations
• Terminology– avoid the use of non-specific terms in describing UT dilation
(e.g. hydronephrosis, pyelectasis, pelviectasis, uronephrosis, UT fullness or prominence, and pelvic fullness)
– Consistently use “UT dilation.”
• Report/communication– Description of the six imaging parameters should be
described in the body of the report and the specific UTDcategory should be in the impression i.e. UTD A1 UTD A2-3, UTD P1, UTD P2, or UTD P3
US parameters used in UTDclassification system
117
UTD classification
118
UTD management
119
Ultrasound appearance of UTD A1. A and B: Fetal kidneys at 19 weeks gestation. anterior-posterior renal pelvis measuring less than 7 mmC and D: Fetal kidneys at 37 weeks gestation. C: anterior-posterior renal pelvis measuring less than 10 mm
Ultrasound appearance of UTD A2-3
Examples
Appearance of normal kidneys on postnatal ultrasound.
A: Imaging in the transverse plane demonstrates an anterior posterior renal pelvis diameter (APRPD) < 10 mm, which is normal for age. Note that the APRPD is measured at the maximal diameter of intrarenal pelvis dilation rather than that of extrarenal pelvis dilation.
B: Imaging in the sagittal plane demonstrates normal renal parenchyma without any calyceal dilation. The bladder is
normal (not shown), and the ureters are not visualized.
A: APRPD 10 to <15 mm. B: central but no peripheral calycealdilation. Renal parenchyma is otherwise normal. C: APRPD <10 mm. D: central calyceal dilation.
UTD P1
UTD P2
A: APRPD 15 mm. B: peripheral calyceal dilation but normal renalparenchymal thickness and appearance. No bladder abnormalities C: APRPD <10 mm. D: peripheral and central calyceal dilation.
UTD P3
A: Imaging in the transverse plane demonstrates an anterior-posterior renal pelvis diameter (APRPD) 15 mm with peripheral calyceal dilation.
B: Imaging in the sagittal plane demonstrates parenchymal
thinning and cysts (arrow).
C: Imaging of the bladder demonstrates increased wall thickness.
Normal Neonatal Kidneys
2-day-old girl
Slightly increased echogenicity of the renal cortex with hypoechoic pyramids is within normal limits for a newborn.
Normal Neonatal Kidneys
1-day-old boy
Slightly increased echogenicity at the bases of the pyramids.
Tamm-Horsfall Proteinsuromodulin
Case One
Enlarged kidneys that are increased in echogenicity with innumerable tiny cysts.
Case One
AUTOSOMAL RECESSIVE POLYCYSTIC KIDNEY DISEASE
Case Two
3-year-old with hematuria
Hypoechoic mass in the upper pole of the right kidney.
Case Two
3-year-old with hematuria
WILMS TUMOR
Case Two
3-year-old with hematuria
WILMS TUMOR
Case Three
3-month-old with flank mass
Multiple cysts of varying sizes that do not communicate with each other.
No appreciable normal renal parenchyma.
Case Three
3-month-old with flank mass
MULTICYSTIC DYSPLASTIC KIDNEY
Case Four
5-year-old with multiple urinary tract infections
Dilated renal pelvis and calyces in upper and lower kidney. Dilated proximal ureter.
Case Four
5-year-old with multiple urinary tract infections
Dilated and tortuous ureter
Case Four
5-year-old with multiple urinary tract infections
Case Four
5-year-old with multiple urinary tract infections
Duplicated collecting system with dilatation of collecting systems of both moieties with
dilated and tortuous ureter.
Case Four
5-year-old with multiple urinary tract infections
Right ureterocele.
Case Four
5-year-old with multiple urinary tract infections
Images of the bladder from VCUG show an ovoid filling defect at the right bladder base.
Case Four
5-year-old with multiple urinary tract infections
ECTOPIC URETEROCELE
Case Four
5-year-old with multiple urinary tract infections
GRADE 5 VESICOURETERAL REFLUX INTO LOWER MOEITY
(a) Radiograph obtained at excretory urography in a 1-month-old female patient in the supine
position
Callahan M J Radiology 2001;219:226-228
©2001 by Radiological Society of North America
Case Four
Case Five
2-year-old with urinary tract infections
Case Five
2-year-old with urinary tract infections
Case Five
2-year-old with urinary tract infections
Case Six
2-year-old with urinary tract infections
NEUROBLASTOMA
Case Six
2-year-old with urinary tract infections
Case Seven
6-month-old with palpable abdominal mass
Case Seven
6-month-old with palpable abdominal mass
Case Seven
6-month-old with palpable abdominal mass
CYSTIC WILMS
Case Seven
6-month-old with palpable abdominal mass
CYSTIC WILMS TUMOR
Case Eight
CLEAR CELL CARCINOMA
2-year-old with palpable abdominal mass on the left
Case Eight
2-year-old with palpable abdominal mass on the left
CLEAR CELL CARCINOMA
Case Nine
6-year-old girl with hematuria
MEDULLARY NEPHROCALICINOSIS
Case Nine
6-year-old girl with hematuria
MEDULLARY NEPHROCALICINOSIS NORMAL
Case Nine
6-year-old girl with hematuria
STAGHORN CALCULUS NORMAL
Case Nine
6-year-old girl with hematuria
STAGHORN CALCULUS
Case Nine
6-year-old girl with hematuria
STAGHORN CALCULUS
Case Ten
6-year-old girl with hematuria
STAGHORN CALCULUS
Case Ten
2-month-old boy with flank mass
URETEROPELVIC JUNCTION OBSTRUCTION
Case Ten
2-month-old boy with flank mass
URETEROPELVIC JUNCTION OBSTRUCTION
Case Eleven
6-month-old boy with oligouria
Case Eleven
6-month-old boy with oligouria
Case Eleven
6-month-old boy with oligouria
Case Eleven
6-month-old boy with oligouria
POSTERIOR URETHRAL VALVES
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