RENAL ULTRASOUND

Diana Pancu, MD
Left: prostate showing a hypoechoic Right: with biopsy needle
Lesion suspicious for cancer
 Objectives

• Clinical indications for performing ED renal US

• Approach to performing the US study
• Normal anatomy
• Abnormal findings
• Clinical Impact
 Clinical Indications for ED
Renal Ultrasound

• Suspected renal colic

– Colicky flank pain radiating to groin
– Hematuria
• Clinical question:
– Presence of hydronephrosis
– Absence of other pathology (AAA)
 Performing the Study
• Patient preparation:
– none
• Transducer: 3.0MHz or 3.5 MHz
– 5.0 MHz for thin patient
• Patient positioning
– Supine
– Posterior oblique, lateral decubitus, prone
 Anatomy
• Kidneys are retroperitoneal, T12 - L4
• Right kidney is lower than the left kidney
• Right kidney is posterio-inferior to liver &
gallbladder
• Left kidney is inferior-medial to the spleen
• Adrenal glands are superior, anterior,
medial to each kidney
 Hepatic
Veins

Spleen
Celiac
axis

Liver
SMA Left
Right
Renal artery kidney
kidney
Renal vein
Renal Scanning Approaches
 Approach to Scanning

LIVER STOMACH

I
K AORTA K
IVC
S
• Right kidney scanning • Left kidney: requires a posterior
approach: anterior, approach, through the spleen
lateral, posterior
• Liver is the acoustic • Air-filled bowel impedes
window anterior scanning
 Anatomy
• 9-12 cm long, 4-5 cm wide, 3-4 cm thick
• Gerota’s fascia encloses kidney, capsule,
perinephric fat
• Sinus
– Hilum: vessels, nerves, lymphatics, ureter
– Pelvis: major and minor calyces
• Parenchyma surrounds the sinus
– Cortex: site of urine formation, contains nephrons
– Medulla: contains pyramids that pass urine to minor
calyces. Columns of Bertin separate pyramids
Medullary pyramids
Kidney Anatomy
Minor
Calyx

Major
Calyx

Sinus

Medulla

Renal capsule Cortex

 Sonographic Appearance
• Ureters are normally not seen
• Renal pelvis is black when visible
• Renal sinus is echogenic due to fat
• Medullary pyramids are hypoechoic
• Cortex is mid-gray, less echogenic than
liver or spleen.
• Capsule is smooth and echogenic
Right Kidney Long Axis
Right Kidney Long Axis
Anterior

Superior Inferior
Liver
Sinus
Cortex
Diaphragm

Posterior
Right Kidney Short Axis
Right Kidney Short Axis
Anterior

Right GB Liver
Left
IVC

R Kidney
Vertebral
Aorta
Body Renal a.

Posterior
Left Kidney Long Axis
Left Kidney Long Axis

Anterior

Superior Inferior

Rib
Shadow

Kidney
Posterior
Spleen
Left Kidney Short Axis
Left Kidney Short Axis

Anterior

Right Liver Left

Spleen

L Kidney

Posterior
 Common Pitfalls in
Renal Scanning
• Failure to scan both kidneys
• Mistaking prominent renal pyramids for
hydronephrosis
• Mistaking prominent pyramids for cysts
• Confusing normal renal arteries for the
ureter
 Common Pitfalls in
Renal Scanning

• Failure to scan through the bladder to search

for stone at the uretero-vesicular junction
• Inability to visualize left kidney due to
anterior probe placement
• Failure to scan the aorta in suspected renal
colic
 Normal Variants
• Dromedary humps:
– Lateral kidney bulge, same echogenicity as the cortex
• Hypertrophied column of Bertin:
– Cortical tissue indents the renal sinus
• Double collecting system:
– Sinus divided by a hypertrophied column of Bertin
• Horseshoe kidney:
– Kidneys are connected, usually at the lower pole
• Renal ectopia:
– One or both kidneys outside the normal renal fossa
 Clinical Indications

1. Obstructive Uropathy
 Nephrolithiasis

• 12% of the US population

• Incidence of renal colic is 3% with
50% recurrence within 10 years

– Manthey DE. Emerg Med Clin North Am.2001;

19(3): 633-54
 Radiographic Modalities

Radiography
• 62% Sensitivity, 67% Specificity

– Sharma RN, Shah I, Gupta S, et al:

Thermogravimetric analysis of urinary stones.
Br J Urol 64:564-566, 1989
 Radiographic Modalities

IVP vs. US
• Prospective study, 85 patients
ULTRASOUND IVP
Sensitivity=85% Sensitivity=90%
Specificity=92% Specificity=94%

– Sinclair D, Wilson S, Toi A, et al. Ann Emerg

Med 18:556-559, 1989
 Radiographic Modalities

ED Ultrasound + KUB vs. IVP

• Prospective study, 108 patients
Sensitivity = 97% PPV = 81%
Specificity = 59% NPV = 92%
Sensitivity = 97%
Specificity = 59%

Henderson, S, et al: Acad Emerg Med.1998;5:666-671.

 Radiographic Modalities

Helical CT- Gold Standard

• Accurate, fast, no contrast
• Identifies presence and size of stone

• Location of stone
• Level of obstruction
• Other sources of pain
 Stone on CT
• Usually visualized
• Not visualized
– Stone is extremely small < 1 mm
– Stone is of relatively low CT attenuation:
Indinavir stones
– Stone excluded from imaging due to respiratory
variation
 Helical CT
Secondary Findings
Sensitivity
• Ureteral dilatation 90%
• Perinephric stranding 82%
• Collecting system
dilatation 83%
• Renal enlargement 71%
Specificity
• Ureral dilatation 93%
• Perinephric stranding 93%
• Collecting system
dilatation 94%
• Renal enlargement 89%

Smith. AJR Am J Roentgenol 167:1109-1113, 1996

 Location of Stone
• 378 patients
• Rate of spontaneous stone passage
• 22% for proximal ureteral stones
• 46% for midureteral stones
• 71% for distal ureteral stones

– Morse R. J Urol. 1991; 145:263-265

 Width of Stone
• 520 patients
• Rate of spontaneous stone passage
– 100% for stones that were 1 mm or smaller in width
– 90% for stones 2 to 3 mm
– 80% for stones that were 4 mm
– 55% for stones that were 5 mm
– 35% for stones that were 6 mm
– 25% for stones that were 7 mm
– 12% for stones that were 8 mm
• Ueno A. Urology. 1977; 10:544-546
 Radiographic Modalities

Ultrasound
• Fast
• Can identify other causes of pain
• Safe in pregnant patients, children
 Hydronephrosis

Dilatation of the urinary tract at any level

secondary to intrinsic and or extrinsic
obstruction to urine flow
 Hydronephrosis
• Intrinsic, acquired • Intrinsic, congenital
– Renal lithiasis – Stenosis (ureteral,
– Neoplasm (renal, ureteral, bladder) urethral, meatal)
– Papillary necrosis – Adynamic ureter
– Ureterocele – Spinal cord defects
– Blood clot – Duplication of the
– Neurogenic bladder ureter
– Anticholinergics – Ureterocele
– Pregnancy, PID, uterine prolapse)
– Diuretics
– Vesico-ureteral reflux
– Diabetes insipidus
 Hydronephrosis in Renal Colic

Sensitivity = 90% PPV = 92%

Specificity = 93% NPV = 90%

Smith. AJR Am J Roentgenol. 1996; 167:1109-1113

Sensitivity = 87% PPV = 90%

Specificity = 90% NPV = 89%

Dalrymple. J Urol. 1997; 159:735-740

 Obstructive Uropathy
Grading System - Subjective
• Mild
– Minimal separation of calyces
• Moderate
– Dilation of major and minor calyceal system

• Severe
– Marked dilation of the renal pelvis and thinning
of the renal parenchyma
 Range of Hydronephrosis

Normal Mild Moderate Severe

Mild Hydronephrosis

GB

Kidney Liver
Moderate - Severe
Hydronephrosis

GB

Kidney
Liver Dilated pelvis
Renal Pathology

1. Renal Cysts
 Renal Cysts
• Arise in the renal cortex, commonly single rather
than multiple
• Cysts do not communicate; hydronephrosis does
• Shape is round or oval
• Echo free
• Sharp interface between the mass and renal tissue
• Large renal cysts may be mistaken for aortic
aneurysms
Renal Cysts

Liver
Scatter 20
Cyst Bowel

Kidney
 Problems & Pitfalls

• Mistaking cysts for hydronephrosis

• Mistaking cysts for aortic aneurysm
 Case Presentation
• 40 yo male presents with complaints of
recent severe headaches, diaphoresis,
and palpitations
• PE anxious male
– BP 210/120 HR 145 RR 18 T 99
– Physical exam otherwise normal
Ultrasound of Kidneys

Kidney
Liver

Diaphragm
Rib
Shadow
Mass
 Case Development
• The patient was managed with alpha and
beta-adrenergic blocking agents
• Urine studies revealed elevated
metanepherine and catecholamine levels
• The patient was diagnosed with
pheochromocytoma
Renal Pathology

2. Renal Masses
 Renal Masses
• Ultrasound visualizes most solid and cystic renal masses
• Beyond scope of EM ultrasound
• Appearance
– Irregular borders
– Poorly defined interfaces between mass and kidney
• Complex masses
– Complex ultrasonic appearance
– Cysts or solid masses may represent infection or hemorrhage
– May have fluid levels
 Case Presentation
• 35 year old male with history of Crohn’s presents
with sudden onset of right flank pain. He is
nauseated and has vomited a few times. He
reports hematuria and denies fever, dysuria,
abdominal pain.
 Physical Exam
Young man in moderate distress from pain
• BP 125/67 HR 110 T 98
• Lungs: clear to ascultation
• Heart: Tachycardia without murmur
• Abdomen: soft, non-tender, normal bowel
sounds
• Back: right costo-vertebral angle tenderness
on percussion
 Renal Ultrasound
Right Kidney Left Kidney
Ultrasound

Echogenic
Structure

Distinct Shadow Thin Parenchyma

Dilated Calyces
 CT Results

• Bilateral Staghorn Calculi

• Bilateral moderate hydronephrosis
• Right sided 3 mm stone at the UVJ
Summary & Take-Home Points

• US is an adjunct in the evaluation of

patients with suspected renal colic
– Evaluate kidneys
– Evaluate aorta
• Scan both kidneys
 Renal
Ultrasound

Steve Geiersbach, MS, RT(R), RDMS

 RENAL ANATOMY

MEDULLA
RENAL
CORTEX
RENAL
COLUMN
MAJOR
CALYCES

RENAL
PELVIS RENAL
URETER CAPSULE
MINOR
CALYX
RENAL
MEDULLARY
PYRAMID
 RENAL SONOGRAPHY
• Paired retroperitoneal organs
• Renal sinus- dense central echoes due to
renal fat
– Contains:
• Collecting system: calyces, infundibula, & part of
renal pelvis
– bifid system seen as two separate lobulations
• Renal vessels: renal hilium
• Lymphatics
• Fat
• Fibrous tissues
 RENAL SINUS
• Central area of the kidney
from the medial border
• Bounded by fat
– anteriorly and posteriorly by
fibrous sheath known as
Gerota’s fascia
– laterally by the laterocoronal
fascia which becomes
continuous with peritoneum &
abdominal wall
 RENAL SONOGRAPHY
• Renal parenchyma - 2 parts cortex & medulla
– thickest at the renal poles
• Cortex located between capsule &
medulla
– low level uniform echoes
– less echogenic than liver & spleen
– Columns of Bertin = columns of
cortical tissue located between
pyramids
» can enlarge & mimic a mass
» normal variant
• medulla
– variable in size but average adult kidney
measures 9-12 cm in length; 4-6 cm in width;
2.5-4.0 cm in thickness
– renal volume is estimated by water
displacement
• V = 0.49 x length x width x anterior
posterior dimension
 RENAL SONOGRAPHY
• Renal parenchyma - 2 parts cortex &
medulla
– Medulla
• Pyramids - triangular or
rounded hypoechoic areas
• Rounded zones of decreased
echogenicity between cortex
& renal sinus
• Specular echoes interspersed
at the junction of the cortex
& medulla represents arcuate
arteries & veins (known as
corticomedullary junction)
 RENAL SONOGRAPHY
• Vascular exchange
– renal arteries
• come off of aorta - can be multiple
• right renal artery (RRA) - seen posterior to IVC in
sagittal plane
– renal veins
• come off of IVC
• left renal vein (LRV) - seen between SMA & aorta
in the transverse plane
RENAL ARTERY
 RENAL SONOGRAPHY
• Renal anatomy
– kidney is covered by a true capsule
– kidney is surrounded by perinephric fat
– fat is bounded anteriorly & posteriorly by
fibrous sheath - Gerota’s facia
LEFT RENAL ARTERY and Vein

LRA

LRV
 RENAL SONOGRAPHY
• Congenital variations
– fetal lobulations
– dromedary hump
– agenesis
– ectopic
• cross-fused ectopic - both located on same side and
usually connected
– horseshoe - isthmus of tissue that connects both
kidneys
– pelvic kidney - fails to migrate from pelvic area
during embryology
 RENAL SONOGRAPHY
• Physiology - 3 functions
– filtration
– reabsorbtion
– tubular secretions
• Essential lab values
– BUN - Blood Urea Nitrogen
– Creatinine
 RENAL SONOGRAPHY
• Indications for sonography exam
– hydronephrosis
– non visualization on IVP exam
– evaluation of flank masses
– avoidance of contrast agent (Allergy to IVP
contrast)
– decreased or poor renal function
– evaluation of abscess
– evaluation of renal transplant
– evaluation of urinary bladder
– hematuria & or flank pain
 RENAL SONOGRAPHY
• Imaging technique - no prep necessary
– patient position - oblique & decubitus positions
work the best
– LPO / use liver for acoustic window for
imaging the right
– Rt. Lateral ducubitus best position for left
kidney - use spleen.
– technique setting
• highest frequency possible that allows for proper
penetration
– gain settings are vitally important
 RENAL SONOGRAPHY
• Imaging technique - Complete study
– must be bilateral & include the bladder
– multiple planes including sagittal & transverse
– scan superior to inferior and medial to lateral to
be assured you scan the entire kidney
– compare cortical density to that of the liver
– if hydronephrosis - try to demonstrate the ureter
 RENAL SONOGRAPHY
• Imaging technique - if malignancy is suggested
you must scan & survey for involvement of:
– IVC
– Renal veins
– Liver
– Retroperitonium
 RENAL SONOGRAPHY
• Ureters
– arise as budlike outgrowths from the
mesonephric or Wolffian ducts
– average size 30 cm long 5 mm in diameter
– courses retroperitoneal to the bladder

Bladder
thin walled, smooth & uniform 5mm in diameter
look for abnormal densities or interruptions of the wall
volume = transverse x AP x length
 ADRENAL GLANDS
• Physiology: two endocrine glands
– cortex - secretes steroids
• Mineralocorticoids
• Glucocorticoids
• Sex hormones
– Addison’s disease - hypofunction of adrenal
» hypotension, malaise, anorexia, bronzing of the skin
– Cushing’s disease - oversecretion of adrenal cortex
» increased plasma volume; mild alkalosis, muscle and
bone weakness
 ADRENAL GLANDS
• Physiology: two endocrine glands
– Medulla - produces epinephrine & norepinephrine
• epinephrine - accelerator of the heart
• norepinephrine - vasoconstrictor
– together they breakdown glycogen to glucose