Kidney ultrasound
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Feb 11, 2019
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About This Presentation
Kidney sonography
Slide Content
Topic:
Kidney
Prepared By:
Safi. Khan
Kidney
Prepared By:
Safi. Khan
ANATOMY
Kidneys have a complex internal architecture that is
responsible for producing a variety of internal
echogenicities.
The central renal sinus is composed of fibrofatty tissue that
appears echogenic on sonograms.
Kidneys have a complex internal architecture that is
responsible for producing a variety of internal
echogenicities.
The central renal sinus is composed of fibrofatty tissue that
appears echogenic on sonograms.
The renal vessels and collecting system are occasionally seen
as thin, anechoic, fluid-containing structures located within
the echogenic tissues of the renal sinus.
The lymphatics also pass through the renal sinus, but cannot be
resolved sonographically.
Each kidney consists of multiple functional units called lobes.
The exemplary lobe contains a calyx, a medullary pyramid,
cortical tissue, and vessels.
as thin, anechoic, fluid-containing structures located within
the echogenic tissues of the renal sinus.
The lymphatics also pass through the renal sinus, but cannot be
resolved sonographically.
Each kidney consists of multiple functional units called lobes.
The exemplary lobe contains a calyx, a medullary pyramid,
cortical tissue, and vessels.
In adults there is an average of 11 pyramids and 9 calices, with
some compound calices draining more than one pyramid.
Sonographically the pyramids are cone- or heart-shaped,
hypoechoic structures.
The cortex is slightly more echogenic than the pyramids, although
this distinction is not always apparent.
The cortical echogenicity of the kidney should be equal to or
slightly less than that of the liver and substantially less than
that of the spleen.
some compound calices draining more than one pyramid.
Sonographically the pyramids are cone- or heart-shaped,
hypoechoic structures.
The cortex is slightly more echogenic than the pyramids, although
this distinction is not always apparent.
The cortical echogenicity of the kidney should be equal to or
slightly less than that of the liver and substantially less than
that of the spleen.
The kidneys are slightly ovoid in the axial section, with the
longest dimension directed from anteromedial to
posterolateral.
Therefore long axis views of the kidney will demonstrate a
relatively flat ovoid shape when viewed from an anterolateral
approach.
A wider ovoid shape when viewed from a posterolateral
approach.
longest dimension directed from anteromedial to
posterolateral.
Therefore long axis views of the kidney will demonstrate a
relatively flat ovoid shape when viewed from an anterolateral
approach.
A wider ovoid shape when viewed from a posterolateral
approach.
The size of the kidney varies with the age, sex, height, and weight of
the person.
In adults the average length of the kidney is approximately 10.5 to
11 cm.
The lower and upper limits of normal are approximately 9 and 13
cm, respectively.
the person.
In adults the average length of the kidney is approximately 10.5 to
11 cm.
The lower and upper limits of normal are approximately 9 and 13
cm, respectively.
Normal kidney:
Longitudinal view of right kidney (flat ovoid) from anterolateral
approach (A): using liver as a window and from a
posterolateral approach (B): (wide ovoid) shows a central
echogenic renal sinus (S) and a peripheral hypoechoic renal
cortex; slightly less echogenic than liver. Between the sinus and
cortex are several hypoechoic pyramids (asterisks). (C): High-
resolution view of a renal transplant shows urine in the collecting
system with an infundibulum (I), two calices (C), and their
corresponding pyramids (asterisks).
Longitudinal view of right kidney (flat ovoid) from anterolateral
approach (A): using liver as a window and from a
posterolateral approach (B): (wide ovoid) shows a central
echogenic renal sinus (S) and a peripheral hypoechoic renal
cortex; slightly less echogenic than liver. Between the sinus and
cortex are several hypoechoic pyramids (asterisks). (C): High-
resolution view of a renal transplant shows urine in the collecting
system with an infundibulum (I), two calices (C), and their
corresponding pyramids (asterisks).
TECHNIQUE
The native kidneys are best imaged with a 2- to 5-MHz Sector-
type probes or curved arrays transducer, depending on the
patient’s body habitus and the depth of the kidney.
Higher frequencies linear arrays or curved arrays can usually be
used in renal Transplants.
The native kidneys can be viewed from a variety of approaches.
Upper poles of each kidney are often seen best with the patient
in the supine position and using a high, posterior, intercostal
approach with the liver or spleen as a Window.
The lower poles can be seen best using a subcostal approach,
usually during a deep inspiration.
The native kidneys are best imaged with a 2- to 5-MHz Sector-
type probes or curved arrays transducer, depending on the
patient’s body habitus and the depth of the kidney.
Higher frequencies linear arrays or curved arrays can usually be
used in renal Transplants.
The native kidneys can be viewed from a variety of approaches.
Upper poles of each kidney are often seen best with the patient
in the supine position and using a high, posterior, intercostal
approach with the liver or spleen as a Window.
The lower poles can be seen best using a subcostal approach,
usually during a deep inspiration.
The location of the transducer should be varied from anterior to
lateral to posterior and the patient’s position should be varied
from supine to decubitus until the best view is obtained.
In some people the lower pole of the left kidney can be seen best
from an anterolateral approach with the patient in a right lateral
decubitus position.
This view seems to be especially advantageous in obese patients.
lateral to posterior and the patient’s position should be varied
from supine to decubitus until the best view is obtained.
In some people the lower pole of the left kidney can be seen best
from an anterolateral approach with the patient in a right lateral
decubitus position.
This view seems to be especially advantageous in obese patients.
Length & Width of Normal Kidney
Views including a portion of the liver and spleen are important to
obtain because it is important to compare renal echogenicity
with the liver and spleen.
This allows for detection of abnormally echogenic kidneys, as well
as abnormalities in hepatic and splenic echogenicity.
obtain because it is important to compare renal echogenicity
with the liver and spleen.
This allows for detection of abnormally echogenic kidneys, as well
as abnormalities in hepatic and splenic echogenicity.
It is equally important to visualize the kidneys from a posterior or
posterolateral approach without using the liver or spleen as a
window.
A posterior approach usually gets the transducer closer to the
kidney and often will allow for better visualization and
characterization of common abnormalities such as cysts and
stones
posterolateral approach without using the liver or spleen as a
window.
A posterior approach usually gets the transducer closer to the
kidney and often will allow for better visualization and
characterization of common abnormalities such as cysts and
stones
Value of posterior views. A, Anterior view of the right kidney shows
a hypoechoic mass in the kidney that may be a cyst or a
solid lesion (cursors). B, Posterior view confirms that the lesion is a
simple anechoic cyst.
a hypoechoic mass in the kidney that may be a cyst or a
solid lesion (cursors). B, Posterior view confirms that the lesion is a
simple anechoic cyst.
VARIANTS AND ANOMALIES
The external contour of the kidney is generally smooth. A
common normal variant, called the junctional
parenchymal defect.
It produces a wedgeshaped hyperechoic defect in the anterior
aspect of the kidney near the junction of the upper and
middle thirds.
It occurs because of incomplete embryologic fusion of the
upper and lower poles.
It can be distinguished from a scar or mass by its typical
triangle-shape and location.
The external contour of the kidney is generally smooth. A
common normal variant, called the junctional
parenchymal defect.
It produces a wedgeshaped hyperechoic defect in the anterior
aspect of the kidney near the junction of the upper and
middle thirds.
It occurs because of incomplete embryologic fusion of the
upper and lower poles.
It can be distinguished from a scar or mass by its typical
triangle-shape and location.
A, Longitudinal view shows a triangular echogenic defect (arrow) in
the anterior aspect of the kidney near the junction of the upper
and middle thirds typical of a junctional parenchymal defect.
B, Transverse view shows a similar defect. It show the full extent of
the defect.
the anterior aspect of the kidney near the junction of the upper
and middle thirds typical of a junctional parenchymal defect.
B, Transverse view shows a similar defect. It show the full extent of
the defect.
Lobulation of the external contour of the kidney can also be seen
as a result of persistent fetal lobation.
Fig.,
Fetal lobation. Longitudinal view shows slight indentations on the
external surface of the kidney.
as a result of persistent fetal lobation.
Fig.,
Fetal lobation. Longitudinal view shows slight indentations on the
external surface of the kidney.
A prominent column of cortical tissue occasionally protrudes into
the renal sinus and can simulate a mass. These are called
columns of Bertin and are located in the mid-third of the kidney.
Columns of Bertin have similar echogenicity to the rest of the
cortex and occasionally contain a small hypoechoic region due
to an associated pyramid.
the renal sinus and can simulate a mass. These are called
columns of Bertin and are located in the mid-third of the kidney.
Columns of Bertin have similar echogenicity to the rest of the
cortex and occasionally contain a small hypoechoic region due
to an associated pyramid.
Hypertrophied columns of Bertin. Longitudinal (A) and transverse
(B) views of the left kidney obtained from a lateral approach
demonstrate a rounded masslike structure (cursors) protruding
into the renal sinus. This is isoechoic to the renal cortex, which is
typical of a hypertrophied column of Bertin. In addition, a central
hypoechoic region is also seen, consistent with a renal pyramid
(arrows). Renal pyramids are not always identified within columns
of Bertin.
(B) views of the left kidney obtained from a lateral approach
demonstrate a rounded masslike structure (cursors) protruding
into the renal sinus. This is isoechoic to the renal cortex, which is
typical of a hypertrophied column of Bertin. In addition, a central
hypoechoic region is also seen, consistent with a renal pyramid
(arrows). Renal pyramids are not always identified within columns
of Bertin.
The perinephric fat is typically more echogenic than the kidney. In
rare instances it can be less echogenic and simulate perinephric
Fluid.
Fig.,
Hypoechoic perinephric fat. Longitudinal view of the right (A) and
left kidney (B) shows a rim of hypoechoic fat (asterisks) that
simulates perinephric fluid.
rare instances it can be less echogenic and simulate perinephric
Fluid.
Fig.,
Hypoechoic perinephric fat. Longitudinal view of the right (A) and
left kidney (B) shows a rim of hypoechoic fat (asterisks) that
simulates perinephric fluid.
Isolated duplication of the intrarenal collecting system produces
a separate central echogenic complex in the upper and lower
poles.
Fig.,
Renal duplication. Longitudinal view shows a band of cortical
tissue separating the renal sinus into a superior and inferior
component.
a separate central echogenic complex in the upper and lower
poles.
Fig.,
Renal duplication. Longitudinal view shows a band of cortical
tissue separating the renal sinus into a superior and inferior
component.
Complete ureteral duplication refers to two ureters that insert into
the bladder or other pelvic structures separately.
The ureter to the upper pole system typically inserts ectopically in a
location that is medial and inferior to the lower pole ureter.
This is referred to as the Weigert-Meye rule.
Insertion may occur in the urethra below the external sphincter,
resulting in incontinence, or in the vagina, resulting in persistent
drainage.
the bladder or other pelvic structures separately.
The ureter to the upper pole system typically inserts ectopically in a
location that is medial and inferior to the lower pole ureter.
This is referred to as the Weigert-Meye rule.
Insertion may occur in the urethra below the external sphincter,
resulting in incontinence, or in the vagina, resulting in persistent
drainage.
Renal duplication with upper pole obstruction. A, Longitudinal
view of the left kidney shows a dilated obstructed upper pole
collecting system (U).
B, TVS view shows a dilated distal left ureter (U) posterior to the
bladder (B).
C, TVS view shows the distal left ureter (U) and the urethra
(arrows) and an irregular connection between the two
(arrowhead).
A
view of the left kidney shows a dilated obstructed upper pole
collecting system (U).
B, TVS view shows a dilated distal left ureter (U) posterior to the
bladder (B).
C, TVS view shows the distal left ureter (U) and the urethra
(arrows) and an irregular connection between the two
(arrowhead).
A
Renal duplication with upper pole obstruction.
Transverse (A) and longitudinal (B) views of the left kidney show a
dilated obstructed upper pole collecting system and proximal
ureter (U).
C, Longitudinal view of the pelvis shows a dilated distal left ureter
(U) posterior to the bladder (B).
Transverse (A) and longitudinal (B) views of the left kidney show a
dilated obstructed upper pole collecting system and proximal
ureter (U).
C, Longitudinal view of the pelvis shows a dilated distal left ureter
(U) posterior to the bladder (B).
Agenesis is associated with an empty renal fossa and an
elongated ipsilateral adrenal gland.
Fig., A, Longitudinal view of the left upper quadrant shows an
empty renal fossa inferior to the spleen.
B, Transverse view of the pelvis shows a normal right seminal
vesicle (cursors) but an absent left seminal vesicle. Transverse
view of the left (C) and right (D) spermatic cords shows bilateral
testicular arteries (arrowheads) and a right vas deferens (arrow),
but an absent left vas deferens.
elongated ipsilateral adrenal gland.
Fig., A, Longitudinal view of the left upper quadrant shows an
empty renal fossa inferior to the spleen.
B, Transverse view of the pelvis shows a normal right seminal
vesicle (cursors) but an absent left seminal vesicle. Transverse
view of the left (C) and right (D) spermatic cords shows bilateral
testicular arteries (arrowheads) and a right vas deferens (arrow),
but an absent left vas deferens.
Renal (A) agenesis, (B) dysplasia, and (C) hypoplasia.
Seminal Vesical
Spermatic Cord
Ectopic kidneys:
It can also appear as an empty renal fossa. Most ectopic kidneys
are found inferior to the renal fossa, often in the pelvis. Pelvic
kidneys are almost always malrotated (with the renal hilum
directed anteriorly), and this can sometimes lead to a confusing
Appearance.
It can also appear as an empty renal fossa. Most ectopic kidneys
are found inferior to the renal fossa, often in the pelvis. Pelvic
kidneys are almost always malrotated (with the renal hilum
directed anteriorly), and this can sometimes lead to a confusing
Appearance.
Pelvic kidney. A, Longitudinal view of the right upper quadrant
shows the liver (L) and psoas muscle (P) and no kidney.
B, Longitudinal view of the right iliac fossa shows the malrotated
right kidney (cursors) with the renal sinus (S) directed
anteriorly.
C, Panoramic view shows the pelvic kidney (K) between the
liver (L) and the bladder (B).
shows the liver (L) and psoas muscle (P) and no kidney.
B, Longitudinal view of the right iliac fossa shows the malrotated
right kidney (cursors) with the renal sinus (S) directed
anteriorly.
C, Panoramic view shows the pelvic kidney (K) between the
liver (L) and the bladder (B).
Crossed, fused renal ectopy may appear as an unusually large
kidney with a duplicated renal sinus or as a mass arising from the
lower pole.
Kidneys can also be mobile and vary in location depending on the
position of the patient.
Ptotic kidney. A, Transverse view of the lower abdomen with the
patient in a left lateral decubitus position shows the aorta (A) and
vertebral body (V). The kidney (K) is in a transverse position and
is located anterior to the aorta.
B, Similar view with the patient in a supine position shows the kidney
in a normal location to the right of the vertebral body.
kidney with a duplicated renal sinus or as a mass arising from the
lower pole.
Kidneys can also be mobile and vary in location depending on the
position of the patient.
Ptotic kidney. A, Transverse view of the lower abdomen with the
patient in a left lateral decubitus position shows the aorta (A) and
vertebral body (V). The kidney (K) is in a transverse position and
is located anterior to the aorta.
B, Similar view with the patient in a supine position shows the kidney
in a normal location to the right of the vertebral body.
Fusion anomalies are relatively common (1 in 250). The
most common fusion anomaly is the horseshoe kidney. It
appears as a variably thick band of renal tissue (or rarely as
a thin fibrous band) extending from both lower poles to
connect anterior to the aorta below the level of the inferior
mesenteric artery It should also be suspected
on longitudinal scans of the aorta when an oval-shaped
hypoechoic mass is seen anterior to the distal aorta.
most common fusion anomaly is the horseshoe kidney. It
appears as a variably thick band of renal tissue (or rarely as
a thin fibrous band) extending from both lower poles to
connect anterior to the aorta below the level of the inferior
mesenteric artery It should also be suspected
on longitudinal scans of the aorta when an oval-shaped
hypoechoic mass is seen anterior to the distal aorta.
Horseshoe kidney:
A and B, Transverse views of the lower abdomen in different
patients show a band of renal parenchyma (arrows) of variable
thickness connecting the kidneys anterior to the aorta (A).
C and D, Longitudinal views of the lower abdomen in different
patients show a band of renal tissue (cursors) of variable
thickness passing anterior to the aorta.
E and F, Coronal views of the right and left kidneys in the same
patient show poor visualization and medial deviation of the lower
poles (arrows).
A and B, Transverse views of the lower abdomen in different
patients show a band of renal parenchyma (arrows) of variable
thickness connecting the kidneys anterior to the aorta (A).
C and D, Longitudinal views of the lower abdomen in different
patients show a band of renal tissue (cursors) of variable
thickness passing anterior to the aorta.
E and F, Coronal views of the right and left kidneys in the same
patient show poor visualization and medial deviation of the lower
poles (arrows).
A rare variation of the horseshoe kidney is the pancake kidney
in which fusion occurs in both the lower and upper poles
Pancake kidney. Coronal view from the left side shows
broad connection between the left (L) and right (R) kidneys.
in which fusion occurs in both the lower and upper poles
Pancake kidney. Coronal view from the left side shows
broad connection between the left (L) and right (R) kidneys.
Horseshoe kidney. Transverse static image show a broad
band of renal parenchyma crossing over the aorta (A)
from the right to the left lower pole.
The inferior mesenteric artery (arrow) is seen anterior to the
parenchymal band on the static image and can be seen
arising immediately superior to the parenchymal band.
band of renal parenchyma crossing over the aorta (A)
from the right to the left lower pole.
The inferior mesenteric artery (arrow) is seen anterior to the
parenchymal band on the static image and can be seen
arising immediately superior to the parenchymal band.
OBSTRUCTION
The sonographic diagnosis of obstruction relies on the
detection of a dilated collecting system.
This appears as anechoic spaces that conform to the
expected.
Location and shape of the renal calices and infundibula and
generally communicate with a dilated renal pelvis.
Communication with the renal pelvis is best shown on the
coronal or semicoronal view.
The sonographic diagnosis of obstruction relies on the
detection of a dilated collecting system.
This appears as anechoic spaces that conform to the
expected.
Location and shape of the renal calices and infundibula and
generally communicate with a dilated renal pelvis.
Communication with the renal pelvis is best shown on the
coronal or semicoronal view.
Marked hydronephrosis (sometimes called grade 3)
refers to severe dilatation that is associated with
cortical thinning.
Moderate hydronephrosis (grade 2) refers
to dilatation of the collecting system that is readily evident
but is not associated with cortical thinning.
Neither moderate nor marked hydronephrosis is difficult to
identify or interpret correctly on sonograms.
Mild hydronephrosis (grade 1) refers to minimal amounts
of urine producing slight distention of the collecting system.
refers to severe dilatation that is associated with
cortical thinning.
Moderate hydronephrosis (grade 2) refers
to dilatation of the collecting system that is readily evident
but is not associated with cortical thinning.
Neither moderate nor marked hydronephrosis is difficult to
identify or interpret correctly on sonograms.
Mild hydronephrosis (grade 1) refers to minimal amounts
of urine producing slight distention of the collecting system.
Hydronephrosis in different patients with different grades of
hydronephrosis.
Longitudinal views show mild (A), moderate (B), and severe (C)
hydronephrosis with cortical thinning. D, Transverse view of the
upper pole of the kidney shows moderate hydronephrosis
(cursors).
hydronephrosis.
Longitudinal views show mild (A), moderate (B), and severe (C)
hydronephrosis with cortical thinning. D, Transverse view of the
upper pole of the kidney shows moderate hydronephrosis
(cursors).
Hydronephrosis due to an enlarged bladder.
A, Longitudinal view of the kidney shows moderate
hydronephrosis.
B, Postvoid view shows almost complete resolution of the
hydronephrosis.
A, Longitudinal view of the kidney shows moderate
hydronephrosis.
B, Postvoid view shows almost complete resolution of the
hydronephrosis.
CYSTIC DISEASES
Benign Cysts
Renal cysts are the most common renal mass. Their frequency
increases with age and they are present in half of the
population above the age of 50.
To qualify as a simple cyst, the lesion should have the
following characteristics:
1. Anechoic lumen
2. Well-defined back wall
3. Acoustic enhancement deep to the lesion
4. No measurable wall thickness
Not all features need to be evident on every view.
Benign Cysts
Renal cysts are the most common renal mass. Their frequency
increases with age and they are present in half of the
population above the age of 50.
To qualify as a simple cyst, the lesion should have the
following characteristics:
1. Anechoic lumen
2. Well-defined back wall
3. Acoustic enhancement deep to the lesion
4. No measurable wall thickness
Not all features need to be evident on every view.
Simple renal cysts.
Moderate-sized (A) and small (B) renal cysts (cursors). Both are
anechoic with welldefined back walls. The larger cyst shows
increased through transmission.
Moderate-sized (A) and small (B) renal cysts (cursors). Both are
anechoic with welldefined back walls. The larger cyst shows
increased through transmission.
Hemorrhagic cysts.
A, Cyst (cursors) with diffuse homogeneous low-level internal
reflections due to cellular material floating in the lumen.
B, Cyst (cursors) with heterogeneous low-level echoes
throughout the lumen.
C, Cyst (cursors) with low-level echoes and irregular,
hyperechoic, solid material in the lumen. This appearance
simulates a cystic renal cell cancer.
A, Cyst (cursors) with diffuse homogeneous low-level internal
reflections due to cellular material floating in the lumen.
B, Cyst (cursors) with heterogeneous low-level echoes
throughout the lumen.
C, Cyst (cursors) with low-level echoes and irregular,
hyperechoic, solid material in the lumen. This appearance
simulates a cystic renal cell cancer.
Calcified cyst.
Oblique view shows a lesion with echogenic walls and posterior
shadowing consistent with a calcified cystic lesion.
The internal aspect of this lesion is not seen adequately to
exclude neoplasm.
A subsequent CT scan confirmed a calcified cyst without
enhancement.
Oblique view shows a lesion with echogenic walls and posterior
shadowing consistent with a calcified cystic lesion.
The internal aspect of this lesion is not seen adequately to
exclude neoplasm.
A subsequent CT scan confirmed a calcified cyst without
enhancement.
Small cyst containing crystals.
Transverse view shows an echogenic lesion in the renal cortex
(arrow).
The cyst is too small to resolve any fluid and all that is seen is the
bright reflections from the crystals.
Transverse view shows an echogenic lesion in the renal cortex
(arrow).
The cyst is too small to resolve any fluid and all that is seen is the
bright reflections from the crystals.
Renal stones.
A, Transverse view shows a stone (arrow) with posterior
shadowing.
B, Transverse view shows hydronephrosis and a shadowing stone
(arrow) in a dilated calyx.
A, Transverse view shows a stone (arrow) with posterior
shadowing.
B, Transverse view shows hydronephrosis and a shadowing stone
(arrow) in a dilated calyx.
Stone with twinkle artifact.
Dual gray-scale and color Doppler views show a twinkle artifact
(arrow) on color Doppler but no visible stone on gray scale
Dual gray-scale and color Doppler views show a twinkle artifact
(arrow) on color Doppler but no visible stone on gray scale
Arterial calcification.
A, Longitudinal view shows a bright shadowing reflector (arrow) in
the upper pole that simulates a stone.
B, Transverse view of the same area shows bright, linear reflectors
arranged as parallel lines (arrow) with associated posterior
shadowing. This is typical of arterial calcification.
A, Longitudinal view shows a bright shadowing reflector (arrow) in
the upper pole that simulates a stone.
B, Transverse view of the same area shows bright, linear reflectors
arranged as parallel lines (arrow) with associated posterior
shadowing. This is typical of arterial calcification.
Ureteral stones.
A, Longitudinal static view of the distal left ureter show a
shadowing stone (arrow) several centimeters above the
ureteral orifice.
B, Longitudinal static view of the distal right ureter show a
stone (arrow) in the ureteral orifice.
A, Longitudinal static view of the distal left ureter show a
shadowing stone (arrow) several centimeters above the
ureteral orifice.
B, Longitudinal static view of the distal right ureter show a
stone (arrow) in the ureteral orifice.
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