(renal) ultrasound for the clinical nephrologist
TRANSCRIPT
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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