Doppler ultrasound of the kidneys

Dr. Muhammad Bin Zulfiqar

PGR FCPS SHL
 Doppler US of the kidneys

• Normal anatomy of the kidney

• Normal US of the kidney
• Normal Doppler US of the kidney
• Indications of renal Doppler US
 Normal anatomy of the kidney

Renal parenchyma: cortex & medullary pyramids

Renal sinus: arteries, veins, lymphatics, collecting system, & fat
Renal hilum: Concave, in continuity with renal sinus
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
 Anatomy of renal arteries

RRA: Usually passes posterior to inferior vena cava

LRA: Usually courses posterior to left renal vein
Multiple renal arteries in 25% (inferior polar artery from aorta)
 Arterial blood supply to the Kidney

Main renal artery

Segmental artery
Apical, upper, middle, lower, posterior

Interlobular artery
Between renal pyramids

Arcuate artery
Between cortex & medulla

Glomerular arteriole

Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
 Left renal vein

• Longer than right renal vein

• Averages 85 mm in length (range: 60 – 110 mm)
• Joined by adrenal, gonadal, lumbar, & hemiazygous
veins before crossing the aorta
• Different types: Pre-aortic 80 – 95%
Retro-aortic 2 – 3%
Circum-aortic 7 – 9%

Sidhu R et al. Semin Ultrasound CT MRI 2009 ; 30 : 271 – 288.

 Variants of left renal vein
Retro-aortic LRV Circum-aortic LRV

Incidence: 2 – 3% Incidence: 7 – 9%

Sidhu R et al. Semin Ultrasound CT MRI 2009 ; 30 : 271 – 288.

 Left-sided IVC
Normal anatomy of IVC Anomalous left-sided IVC

Persistence of embryological AV

Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
 Doppler US of the kidneys

• Normal anatomy of the kidney

• Normal US of the kidney
• Normal Doppler US of the kidney
• Indications of renal Doppler US
 Gray scale imaging first

• Kidneys Maximum renal length

Echogenicity of renal cortex
Thickness of renal cortex
Masses – hydronephrosis – renal calculi
• Aorta Plaque – thrombus – dissection – aneurysm
• Adrenal glands
 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)

Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3 rd edition, 2005.
 Renal dimensions

• Length of normal kidney: 9 – 14 cm

Right kidney smaller than left kidney
• Discrepancy > 2 cm between two kidneys:
Considered significant & needs further evaluation
• Renal length between 8 – 9 cm
Correlated to patient’s phenotype particularly height
• Renal length < 8 cm definitely reduced
Should be attributed to chronic renal failure

Fiorini F et al. J Ultrasound 2007 ; 10 : 161 – 167.

Measurement of parenchymal & cortical thickness

Cortical thickness: Normal 8 – 10 mm

Parenchymal thickness: Normal 14 – 18 mm

Tuma J et al. European course book: Genitourinary ultrasound.

European Foundation of Societies of Ultrasound in Medicine & Biology.
 Renal volume
Length: 9 – 14 cm (longitudinal section)
Width: 4 – 6 cm (cross section)
Depth: 4 – 6 cm (cross section)
Ellipsoid formula: length . width . thickness . π/6

Adjusted to BMI
(V / BMI) . 25

Appropriate renal volume

231 ± 50 ml
Derchi LE et al. Acad Radiol 1994 ; 1 : 100 – 105.
Fiorini F et al. J Ultrasound 2007 ; 10 : 161 – 167.
Classification of renal parenchymal echogenicity

4 types based of US appearance

Grade 0 Hypoechoic compared to liver Normal
Grade I Isoechoic compared to liver Normal
Grade II Hyperechoic compared to liver Pathological
Grade III Isoechoic to renal sinus Pathological
Kidney parenchyma compared to liver parenchyma
Hypoechoic Isoechoic

Hyperechoic

Fiorini F et al. J Ultrasound 2007 ; 10 : 161 – 167.

 Congenital normal variants of kidney

• Dromedary hump
• Persistent fetal lobulation
• Prominent column of Bertin
• Junctional parenchymal defect
• Hypoechoic renal sinus

Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.

 Dromedary hump
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

Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.

 Persistent fetal lobulation

Renal surface indentations between pyramids

May be single or multiple

Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.

 Prominent column of Bertin (PCB)
Mistaken for intrarenal tumor

Continuity with renal cortex

Similar echo pattern as renal parenchyma
Similar vascular pattern by color & power Doppler
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
 Junctional fusion defect
Mistaken for cortical scar or angiomyolipoma

Triangular hyperechoic structure Continuity with central

Antero-superior or postero-inferior sinus
surface of kidney by echogenic line
“inter-renicular septum”
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
 Abdominal aorta

• Normal abdominal aorta 1.5 – 2.5 cm

• Ectatic aorta 2.5 – 3 cm

• Aortic aneurysm > 3 cm

• Annual growth of aneurysms 0.33 cm/year

between 4 & 5.5 cm

* Bhatt S et al. Ultrasound Clin 2008 ; 3 : 83 – 91.

 Cross-section at adrenal glands
Compared to seagull, Y, or V letter

Y-shaped structures lying antero-medial to kidneys

Composed of body & medial & lateral “wing” or “limb”

Tuma J et al. European course book: Genitourinary ultrasound.

European Foundation of Societies of Ultrasound in Medicine & Biology, 2011.
 US of normal adrenal glands
Documented in 1980 1
Right adrenal gland Left adrenal gland

Transcostal scan in LLD Transverse scan of epigastrium

Between RLL, IVC & diaphragm Dorsal to pancreatic tail & SV

With modern equipment (high-resolution) & good training

US can image right gland in 99% & left gland in 70%1

1
Dietrich CF et al. Endoscopy 1997 ; 29 : 859 – 864.
2
Jenssen C et al. Ultraschall Med 2010 ; 31: 228 – 250.
Normal adrenal gland / Inverted Y-shape
Coronal scan of right upper abdomen through MAL

Hypoechoic right adrenal gland

Horizontally inverted Y-shape

Wan YL. J Med Ultrasound 2007 ;15 : 213 – 227.

 Doppler US of the kidneys

• Normal anatomy of the kidney

• Normal US of the kidney
• Normal Doppler US of the kidney
• Indications of renal Doppler US
 Technical points

• Fasting for at least 6 hours before the exam

• Duration of the examination: 30 – 45 min
• Rare failure: Non-cooperant patient – Gas
• Intestinal preparation: not necessary

Operator-dependent technique
Slow learning curve
Most complex & difficult Doppler examination1
 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
 Transverse scan with probe angulations
Main renal arteries

Schäberle W. Ultrasonography in vascular diagnosis. Springer-Verlag, Berlin, 2 nd edition, 2011.

 Norma right renal artery

Transverse gray scale image Transverse color Doppler image

Right main renal artery Right main renal artery

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

Gray scale alone without color Doppler
Patients with difficulty to hold breath
Gray scale image

Entire RRA well visualized

Color flash artifact from patient motion may obscure visualization
Better spatial resolution & and faster frame rate

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Norma left renal artery

Gray scale image Color Doppler image

Proximal main left renal artery Proximal main left renal artery

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 ‘‘banana peel’’ or “Isikoff” view
Longitudinal transhepatic view in Left lateral decubitus
Gray scale image Color Doppler image

Origins of right & left renal arteries Origins of right & left renal arteries

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

Isikoff MB et al. Am J Roentgenol 1980 ; 134 : 1177 – 1179.
 Normal right renal artery
Coronal images of IVC

RRA is the only vessel to course laterally under the IVC

Often slightly indents the IVC

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

Two renal arteries or early branching?

Longitudinal view of IVC Transverse view of aorta

Two right renal arteries Early branching of RRA

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

Longitudinal scan in left lateral decubitus
Multiple renal arteries (25%)

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Two left renal arteries
Dominant left renal artery Accessory left renal artery

PSV: 90 cm/sec PSV: 60 cm/sec

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Axial scan in left lateral decubitus
Using right kidney as acoustic window
Schematic drawing Color Doppler US

Right main renal artery & vein

Meola M et al. J Ultrasound 2008 ; 11 : 55 – 73.

Axial scan in right lateral decubitus
Using left kidney as acoustic window
Schematic drawing Color Doppler US

Left main renal artery & vein

Zubarev AV. Eur Radiol 2001 ; 11 : 1902 – 1915.

Pre caval right renal artery
Pre-aortic left renal vein (80 – 95%)

Reduction in diameter in pre-aortic segment to IVC

with physiologic acceleration

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Left renal vein variants

Retro-aortic LRV (2 – 3%) Circum-aortic LRV (7 – 9%)

Pre & retro-aortic LRV

Sidhu R et al. Semin Ultrasound CT MRI 2009 ; 30 : 271 – 288.

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.
Color Doppler of RRV & retro-hepatic IVC
Righ renal vein Inferior vena cava

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Pulsed Doppler of renal veins
Left renal vein Right renal vein

Little modulation Resembles pulsed Doppler of IVC

Wall artifact due to systolic peak Triphasic waveform

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 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%
Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.
 Angle of insonation
Difficulty in case of tortuous or curved renal artery

Incorrect angle Correct angle

Schäberle W. Ultrasonography in vascular diagnosis.

Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
 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
Normal segmental & interlobar renal arteries

Color Doppler image of the kidney

Normal segmental renal arteries (long arrows)

Normal inter-lobar renal arteries (short arrows)

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Study of intra-renal arteries
Perfusion study / Low PRF

Cortical perfusion
Tumoral vascularization

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 Study of intra-renal arteries
Morpho-hemodynamic study

Intermediate PRF

Arterio-venous fistula
Pseudo-aneurysm

High PRF

Renal stones
Vascular calcifications

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 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.

Normal pulse Doppler waveform
Renal segmental artery

Sharp systolic upstroke

Low resistance waveform
Continuous forward diastolic flow
 Pourcelot’s resistive index

RI S – ED / S
Normal 50 – 70 %
Abnormal > 80 %
 Accleration time (AT)
or Rise time (RT)

• Length of time in sec from

onset of systole to peak systole

• Normal value: < 0.07 second

 Acceleration Index (AI)
Systolic upslope/transducer frequency

X (KHz)
AI =
Probe frequency (MHz)

Normal value: > 3.5 m/s2

Measurement of PSV

Early systolic peak

Biphasic with late systolic peak

Monophasic with late systolic peak

Am J Roentgenol – Dec 1995

 Early systolic notch

Some normal waveforms have early systolic notch

1. Measuring to point of PSV results in prolonged AT & AI

2. Excellent negative predictive value of stenosis > 60%

Moukaddam H et al. Ultrasound Clin 2007 ; 2 : 455 – 475.

 Extrasystole

Correct RI calculated in normal sinusoidal rhythm

Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.

 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