Psychiatry Overview

(Renal) Ultrasound for the Clinical Nephrologist

Adina S Voiculescu, MD

Associate Physician

Renal Division/Department of Medicine

Brigham and Women’s Hospital

Adina Voiculescu, MD, FASDIN

• University of Dusseldorf Medical School/Germany

• Nephrology Fellowship – Mass General Brigham

• General and Interventional Nephrologist

• Director of Ultrasound in Nephrology, BWH

• Assistant Professor of Medicine@ HMS– Clinical focus: Imaging– Research focus: Imaging and

Hemodynamics

Disclosures

None

Objectives

• Use 2 case vignettes to:

–Highlight the use and interpretation of renal ultrasound while looking at ultrasound images

–Review strengths and limits of ultrasound and appropriateness of imaging studies in nephrology

Ultrasound – the extension of your physical

exam

HPI: A 24 year old F, presents with sudden onset of swelling and discomfort in her legs. She had one episode of nausea and vomiting two weeks ago.

Clinical exam: BP136/89, HR 88, 97.5, weight 115 lbs (prior 100 lbs), RRR, lungs clear, abdomen soft, lower extremity edema

Labs: Sodium 130 mmol/l, Potassium 5.1 mmol/l, Creatinine 3.6mg/dl, BUN 72 mg/dl, bicarb 20 mmol/l, urine analysis: +RBCs, ++WBC, +Protein.

Case

Case - Images Right Kidney Left Kidney

The Ultrasound of the kidney demonstrates

a) Normal size kidney without hydronephrosis on the right

b) Normal size kidney with hydronephrosis on the right

c) Normal size kidneys with cysts on the right

d) Small kidneys without evidence of hydronephrosis

e) Small kidneys with hydronephrosis on the right

Case - Questions

Basics of ultrasound

Basics of ultrasound

EchogenicityAnechoic IsoechoicHypoechoic Hyperechoic

Fluid

CystsHydro

Bladder

Organs

LiverKidneySpleen

Fat/Calcification

Renal sinusPerirenal fat

Kidneys stones

Structures

Used for descriptions

of masses

Basics of ultrasound

Artifacts

StoneBone

Nephrolithiasis

ShadowingExtinction of signal

Dorsal enhancement

CystsBladder

Renal arteryInterlobar artery

Calyx

Pyramid

Cortex

Pelvis

Anatomy of the kidney

Normal kidney

Longitudinal Transversal

Cranial Caudal

Posterior

Anterior

Posterior

Anterior

Right Left

Normal kidneyLongitudinal Transversal

Cranial Caudal

Posterior

Anterior

Posterior

Anterior

Right Left

B mode- size

9.5 cm 8 cm

Size does not necessarily tell you anything about function

Normal size 10-12 cmSize difference of > 1cm indicates scarring - origin could be

vascular, postpyelonephritic or postobstruction

Right Kidney Left Kidney

B mode- size

• Diabetes • Preeclampsia• Acute parenchymal disorder (acute GN, AIN,

renal vein thrombosis)• Infiltrative disease (multiple myeloma, amyloidosis,

lymphoma)

Large kidneys: >12-13 cm

B mode - echogenicity

Kidney with increased echogenicity of the cortex- medical disease

B mode - echogenicity

Kidney with increased echogenicity of the cortex- medical disease

B mode - echogenicity

Kidney with increased echogenicity of the pyramids- medullary nephrocalcinosis

B mode - echogenicity

Kidney with increased echogenicity of the pyramids- medullary nephrocalcinosis

Case - Images Right Kidney Left Kidney

Case

HPI: A 57 year old man with 5 day history of flank pain. Worst pain ever, associated with nausea and vomiting

Clinical exam: 125/49, HR 108, 99.5, in distress, RRR, lungs clear, abdomen distended but soft and tender on the right

Labs: Creatinine 2.3 mg/dl, BUN 57 mg/dl, K 3.8, urine analysis: ++RBC, +WBC,

What image modality would be most appropriate in this setting

a) CT – angiogram with contrast

b) CT-urogram with contrast

c) Renal ultrasound and a KUB

d) Renal ultrasound with Color/Doppler

e) Nuclear scan with Furosemid

Case - Questions

ACR Appropriateness criteriaAKI – Ultrasound +/- Doppler

CKD – Ultrasound +/- Doppler

Renal TX dysfunction – Ultrasound +/- Doppler

Recurring stone disease – Ultrasound

- CT non contrast

Hematuria – CT with and without contrast

- Ultrasound in patients with parenchymal disease

Flankpain - CT without and with contrast

- US of kidneys, bladder and retroperitoneum + KUB

OR CT without contrast

Renal Mass - CT without and with contrast or MRI with contrast

- Ultrasound of kidneys with Doppler

Renal artery stenosis - MRA with contrast

- Ultrasound kidney and Doppler or non contrast MRA

Case - Images

Right Kidney Left Kidney

What do the images show?

a) Normal kidneys bilaterally

b) Normal kidney on the right and cyst on the left

c) Normal kidney on the left and hydronephrosis on the right

d) Hydronephrosis on the right and the left

e) Hydronephrosis on the right and cyst on the left

Case - Questions

B mode- Hydronephrosis

Mild

B mode- Hydronephrosis

Mild

B mode- Hydronephrosis

Moderate

B mode- Hydronephrosis

Moderate

Degree of hydronephrosis does not necessarily correlate with grade of obstruction

B mode- Hydronephrosis

Severe

BEAR-PAW

Grading of hydronephrosis

Grade 1

Grade 2

Grade 3

Grade 4

Mild

Moderate

Severe

Pittfalls - HydronephrosisFalse negative findings – obstruction without seeing hydronephrosis➢Retroperitoneal fibrosis➢Retroperitoneal tumors➢Prerenal states/volume depletions➢Early and sudden obstruction

False positive results – hydronephrosis without obstruction➢Pregnancy➢Vesicoureteral reflux➢After relief of obstruction➢Megacystis-megaureter syndrome➢Full bladder➢UTI➢Brisk diuresis as e.g. in nephrogenic diabetes insipidus

Radionuclid Renogram

Tc99 MAG3 or DTPA

Qualitiative evaluation of overall renal function and calculation of differential renal function as well as assessment of perfusion

Diuretic RenographyTc 99 MAG 3 or DTPA

Addition of 20-40 mg Furosemide i.v.

Used to differentiate a dilated but nonobstucted collecting system from dilated system with urodynamically significant obstruction

Renal Nuclear Scan

B mode - CystsKidney with mass

completely anechoic round structure Simple cyst

B mode - CystsKidney with mass– completely anechoic round structure

Simple cyst

renal cyst

liver

posterior enhancement

B mode- echogenicity and shadows

Kidney with hyperechoic areas with acoustic shadowing- nephrolithiasis

B mode- echogenicity and shadows

Kidney with hyperechoic areas with acoustic shadowing- nephrolithiasis

CT scan - non contrast

What image modality would be most appropriate in this setting

a) CT – angiogram with contrast

b) CT-urogram with contrast

c) Renal ultrasound and a KUB

d) Renal ultrasound with Color/Doppler

e) Nuclear scan with Furosemid

Case - Questions

Role of B Mode Ultrasound

• Size and aspect of kidneys ***• Hydronephrosis ***• Polycystic kidney disease ***• Bladder size and aspects, postvoidresiduals ***• Perinephric fluid collections ***• Nephrolithiasis **• Masses: Cysts and tumors **• Biopsies **

All patients with renal disease and hypertension

should obtain

at least one renal ultrasound

Ultrasound B ModeKidney transplant

Possible questions• Size and aspect of kidneys• Hydronephrosis• Perinephric fluid collection• Bladder

• Nephrolithiasis• Biopsies

Important to perform serial exams!

• Renal artery stenosis ***

• Transplant kidney perfusion ***

• Arteriovenous fistulas in kidneys ***

• Transplant renal vein thrombosis ***• Evaluation of renal tumors **

• Renal vein thrombosis native kidney *

Ultrasound with Color and Doppler

Pro: • Inexpensive• Non invasive• Non toxic• Easy to repeat and use for follow up

Contra:• Operator dependent

BUT – everything in medicine and radiology is OPERATOR AND READER DEPENDENT

SummaryUtrasound with B-Mode, Color and Doppler

Point of Care -Volume Exam

FAST - Abdominal Ultrasound

• IVC Diameter and collapsibility

• Pleural effusion

• Ascites

Cardiac Ultrasound

• Parasteral+Subxiphoid view: dilated ventricles, EF, pericardial effusion

Lung Ultrasound

• B lines

• A lines

IVC Ultrasound

Happy Whale Sign

IVC Ultrasound

IVC Sizecm

Percent collapse%

RA Pressure, mm Hg

< 1.51.5-2.51.5-2.5> 2.5

Total collapse> 50%< 50%No collapse

0-56-1010-15> 15

Wide + non collapsing =

elevated CPV

Pleural effusion

Mirror Image Artifact

No Pleural effusion present Pleural effusion present

Positive spine sign

Lung Ultrasound

B- LinesA- Lines

Aerated lung Interstitial thickening

Most frequently fluid

Parasternal long and short axis

Take home message

• Every patient with renal disease and hypertension should have a renal ultrasound …and volume-exam with point of care ultrasound

• Always take a look at the images and not just the interpretation

• Look into learning to perform ultrasound yourself

• Different imaging techniques are available, they all have different strengths and weaknesses and it may be necessary to perform two or three different studies as they are often complementary

References/Resources

• O’Neill C: Sonographic evaluation of renal failure. AJKD 35( 6): 1021-1038, 2000

• Gosmanova E et al. Application of ultrasound in Nephrology practice, Adv Chronic Kidney Disease, 16(5):396-404, 2009

• Moving Points in Nephrology: Renal relevant radiology. Clinical Journal of the Amercian Society of Nephrology, February 2014

• American College of Radiology – Appropriateness creiteria for selection of radiologic imaging: http://www.acr.org/quality-safety/appropriateness-criteria

• Niyyar VD et al. Point of care ultrasound in Nephrology. Kidney International 93: 1052-1059, 2018

• Ross, D et al: Lung Ultrasound in End stage renal disease. Clinical Kidney Journal 11: 172-178, 2018

• Nephropocus – website

• ASDIN (American Society of Diagnostic and Interventional Nephrology) website

• POCUN (point of care ultrasound in nephrology) - website

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