Renal Ultrasound

Chapter 6
Renal Tract Ultrasound

Prep by: Minishir S [MRT]
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Ultrasound of Renal Tract
F0
Fr
9/5/22 Minishir S (MRT) 2

Objectives
Upon completing this unit learners will be able to:
• Recognize and describe normal renal sonographic anatomy and
their appearances.
• List indications and describe protocol for Renal Sonography.
• Identify focal and diffuse lesions of the kidneys on sonography.
• Recognize and describe the sonographic appearance of selected diseases.
9/5/22 Minishir S(MRT) 3

Renal Anatomy
• Is a retroperitoneal organ
• Superoinferior axes=lower ends lying more anteriorly
and laterally.
• Mediolateral axes=anterior surface face
anterolaterally & posterior surface posterolmedially.

Cont’d
• located in the abdominal cavity.
• They are at the level of T12 to L3,
so they are at the costal margin,
and the ribs protect them a little.
 Even though they are protected
by thoracic ribs, they are not in
the thoracic cavity because they
are below the diaphragm.

• cortex
• Renal
pelvis
• pyramids
• calyces

Why Renal Ultrasound?
To identify the cause of:
Flank pain
Haematuria
Classification of a mass (Solid V's cystic)
Post surgical complications
Follow-up of previously identified pathology
Guidance of aspiration, biopsy or intervention
Post injury

What To Check
Kidney size
Cortical thickness(not <1cm)
Cortico-medullary differentiation
Cortex at least as hypoechoic as the liver

Pyramids slightly hypoechoic relative to the cortex
For hydronephrosis
Renal scarring(beware mistaking prominent lobulations
as scars)

Preparation
A) Preparation of patient
No special preparation unless bladder is wanted
B) Positioning a patient
First examined on supine position then decibutus.
C) Choice of transducer:
3.5MHz for adults & 5MHz for children

Scanning Technique
Patient supine
Apply coupling agent
Use liver as acoustic window on the RT side
deep breath
Scanning-longitudinal and transeverse
- coronal- lt or rt lateral decubitus.

Supine; Longitudinal And Transverse

upper abdominal longitudinal scan, Rt side

Longitudinal Rt Kidney

Lateral Decubitus

kidney
Upper abdominal transverse scan, Rt side

Longitudinal flank scan, left side
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Minishir S(MRT)
LK Coronal Scanning

Measuring the size of kidney
Length: craniocadual (find the longest length and

measure it).
Is difficult to measure exactly due to its ellipsoidal
shape.
The length of the of an individual’s Kidney do not
vary by more than 1cm.
The cortical thickness of the kidney is the distance
between the capsule and the margin of the medullary
pyramid.
Width of kidney=4cm-6cm
Normal Renal Sonographic
Appearances
• The 3 main components which can be identified on U/S are
renal cortex,
medulla and
renal sinus

On Ultrasound
 Renal Capsule- echogenic, surrounds cortex of the kidney.
 Cortex- less echogenic than liver and spleen, homogeneous
 Medulla- pyramids found here, hypoechoic to anechoic
 Arcuate Arteries- echogenic dots found at the corticomedullary
junction
 Sinus- hyper echoic

Renal Parenchyma
1) Cortex
Outer portion
Contains renal corpuscle & proximal and distal
convoluted tubules
Filtration takes place

Cortex
located between capsule & medulla
 Low level uniform echoes
 Less echogenic than liver & spleen
 Columns of Bertin = columns of cortical tissue located between pyramids
o can enlarge & mimic a mass

o normal variant
SONOGRAPHIC CRITERIA FOR
HYPERTROPHIED COLUMN
OF BERTIN
• Indentation of renal sinus laterally

• Bordered by junctional parenchymal defect
• Location at junction of upper and middle thirds
• Continuous with adjacent renal cortex
• Contains renal pyramids
• Less than 3 cm in size

2.Medula
o Inner portion
o Contains renal loops
• Loop of Henle
o 8-18 medullary pyramids

o Pyramids are triangular
• Apex-narrow tip
• Base-broad
o Reabsorption takes place

Column of bertin

Renal cortex

Renal pyramid

Renal sinus and collecting system
Renal sinus contains collecting system , renal vessels and fat.
 Seen as echogenic due to fat.
 Amount of fat can vary; tend to increase in obesity and steroid
therapy.
NB;There is increase in size of central echocomplex with age due
to atrophy of parenchyma.

Renal sinus

Normal Variants
Fetal Lobulation
Dromedulary Hump
Hypertrophied Column of Bertin
Double Collecting System
o Renal sinus divided
o Each has a renal pelvis


Humps, lobulation & column of bertin
 Renal margins is normally a smooth curved shape and some
normal variants should be recognized and should not be
mistaken for pathologic changes.
A. Fetal lobulation: is a normal variant seen occasionally in
adult kidneys.
 It occurs when there is incomplete fusion of the developing
renal lobules.
 Embryologically, the kidneys originate as distinct lobules
that fuse as they develop and grow.
 Its renal surface indentation between pyramids.
 It may be single or multiple and produces parenchymal
irregularities.

lobulation

B.SPLENIC HUMP
Due to pressure from spleen on LK.

 are prominent focal bulges on the lateral border of the left
kidney.
 They are normal variants of the renal contour, caused by the
splenic impression onto the superolateral left kidney
 Humps are basically a variation in the shape of the kidney
rather than an area of hypertrophied tissue.
 mimics tumor
 Parenchymal thickness not increased.

Splenic hump

C. Columns of Bertin
 is the extension of renal cortical tissue which separates the

pyramids, and as such are normal structures.
 produced by the fusion of adjacent portion of cortex as renal
lobules fuse.
 parenchymal surface is not distorted.
 No change of echogenecity.

Column of bertin

Etrarenal pelvis
 Renal pelvis projects outside the kidney.
 Transverse section_ ‘baggy’ containing anechoic Urine.
 DDx -dilatation of the PCS or
parapelvic cyst or collection.

Ultrasound images TS through the RK demonstrating
a baggy extrarenal pelvis. The PCS remains undilated,
and this should not be confused with hydronephrosis.

Megapolycalicosis
 Characterized by multiple calyces.
 This malformation goes back to extremely short mark pyramids that
cannot be rendered visible in such images.
 Both the absence of mark pyramids and very many and enlarged
calyces are highly specific for this diagnosis .
 There isn’t any expansions of neither renal pelvis nor outgoing ureter.

Megapolycalicosis

Congenital anomalies
A. Anomalies Related to Ureteral Bud
1.Renal agenesis
 In case of a faulty interaction between Ureteric bud and metanephric blastema, the
kidney’s Aplasy can occur.
 Sometimes, minimal traces of the kidney on a scale of a few millimeters can be
discovered and occasionally, anechoic tubular malformations in the area of the
falsely developed ureters appear

Renal Agenesis
 Unilateral renal agenesis is relatively common.
 left is more commonly the one that is absent.
 The contralateral(opposite to) kidney usually undergoes
compensatory hypertrophy.
 Bilateral renal agenesis incompatible with life.

Cont’d
• .

2. Duplex Collecting System
and Ureterocele
• Duplex collecting system is the most common congenital
anomaly of the urinary tract
• The degree of duplication is variable.
• Duplication is complete when there are two separate
collecting systems and two separate ureters, each with their
own ureteral orifice. Duplication is incomplete when the
ureters join and enter the bladder through a single ureteral
orifice.

Ultrasound finding
• At ultrasound, a duplex collecting system is seen as two
central echogenic renal sinuses with intervening, bridging
renal parenchyma
• Hydronephrosis of the upper-pole moiety and visualization of
two distinct collecting systems and ureters are diagnostic

Cont’d
Sagittal sonogram shows an upper-pole cystic mass. collecting
system dilation Delayed intravenous urogram shows duplicated left
and cortical thinning collecting system and dilated upper-pole moiety.

3.Ureteroceles
• may be unilateral or bilateral and may occur in normal,
duplicated, or ectopic ureters.
• Ureteroceles may result in ureteral obstruction and give rise
to recurrent or persistent urinary tract infections (UTIs).
Ultrasound finding
 A ureterocele will appear as a round, cystic like structure
within the bladder
 Occasionally, it may be large enough to
occupy the entire bladder and will cause obstruction of the
bladder neck.

Cont’d
Small bilateral ureteroceles

4.Supernumerary Kidney
• Supernumerary kidney is an exceedingly rare anomaly.
• The supernumerary kidney is usually smaller than normal
and
• It can be found above, below, in front of, or behind the
normal kidney.
The supernumerary kidney often has only a few calices and a
single infundibulum.
Ultrasound finding
• an extra kidney will be found.

B. Anomalies Related to Ascent
of Kidney
 Are kidneys, which are away from their normal positions.
 Failure to show the kidney in a normal position doesn't
necessarily mean a case of either aplasia or agenesis.
 Deep in the belly is found a pelvic kidney, these ectopic kidney
is often supplied from the iliac artery (similar to the kidney
transplant).

1.Horseshoe kidney
• Horseshoe kidneys occur when metanephrogenic blastema
fuse prior to ascent;
• fusion is usually at the lower poles (95%)’\
 The kidneys are fused at the lower pole, the parenchymal
bridge is located in front of the aorta and should not be
confused with a solid mass .
 Joined by a band of tissue or isthmus

• Typically, the isthmus is composed of functioning renal
tissue, although
• rarely it is made up of fibrous tissue.
Ultrasound finding
• horseshoe kidneys are usually lower than normal, and
the lower poles project medially.
• Transverse imaging of the retroperitoneum will
demonstrate the renal isthmus crossing the midline
anterior to abdominal great vessels.
• Hydronephrosis (pyelocaliectasis) and collecting system
calculi may be evident.

2.Ectopic Kidney
 More common on the left
 The most common ectopic site is in the pelvis.
-The kidney will lie obliquely in the ipsilateral iliac fossa.
 Less commonly, a kidney may ascend to the other side with 2
kidneys on one side of the abdomen;crossed-ectopia.
 This may result in a single large fused kidney as shown below
(crossed-fused-ectopia)

Cont’d
1) Pelvic Kidney
2) Sub Diaphragmatic Or Thoracic Kidney
3) Crossed Ectopia

Pelvic kidney

Thoracic kidney

3.Crossed Renal Ectopia
• In crossed renal ectopia, both kidneys are found on the same
side.
• In 85% to 90% of cases, the ectopic kidney will be fused to
the other kidney.
• The upper pole of the ectopic kidney is usually fused to
the lower pole of the other kidney, although fusion may
occur anywhere
• At sonography, both kidneys are on the same side and are
typically fused .

Cross fused ectopic kidney.
The left kidney is fused to the lower pole
of the right kidney.
Bilateral ectopic fused kidneys

Crossed fused ectopia

4.Nephroptosis
 This is a dynamic anomaly of position.
 While in a lying position, the kidney is to be found in the
normal location, while in a standing position, a dropping by
more than 5 cm is being observed.

Renal Tract Inflammation and Infection
 The most common UTI are bacterial in origin, with viral
and fungal infections being comparatively rare.
 Infection may be via the blood stream (haematogenous) or
the urethra (ascending).
 Also infection is associated with
obstruction ,calculi,diabetes,catheters.

Cont’d
Pyelonephritis
Acute Pyelonephritis
• Acute pyelonephritis is a tubulointerstitial inflammation
of the kidney.
Two routes may lead to inflammation:
• ascending infection ((85% e.g., Escherichia coli) and
• hematogenous seeding (15%; e.g., Staphylococcus aureus).
Most adults present with flank pain and fever and can be
diagnosed clinically with the aid of laboratory studies
(bacteriuria, pyuria, and leukocytosis

Cont’d
 It has classic triads of :
 Flank pain
 Fever
 Costovertebral angle tenderness
It can be diagnosed clinically with laboratory studies
 Neutrophilic leukocytosis,elevated ESR and C-RP
 Elevated serum creatine in severe infection
Urine analysis
Numerous leukocyte and bacteria

U/S FINDING
At ultrasound, the majority of kidneys with acute

pyelonephritis appear normal.
However,ultrasound findings of Acute pyelonephritis include:
 Renal enlargement
 Compression of the renal sinus
 Decreased echogenicity (secondary to edema) or
increased echogenicity (potentially from hemorrhage)
 Loss of corticomedullary differentiation
 Color Doppler .May show ~ renal vascularity or vascular defect
due to vasoconstriction

Cont’d

Chronic pyelonephritis
 usually the result of frequent previous inflammatory/infective
episodes.
 The kidney may be small and often has focal scarring
present; hyperechoic, linear lesion.
 The renal cortex is frequently thin.

Chronic pyelonephritis with irregular destructed kidney

Renal abscess
 Is a progression of focal inflammation in kidney.

 Symptoms
Fever ,chills and pains in back and abdomen

 High risk
DM,Hemodialysis,IV drug abusers

 Management
<3cm Parenteral antibiotics

3-5cm Percutaneous drainage
>5cm surgical drainage

Cont’d
Ultrasound finding
 Form a complex mass with distal acoustic enhancement.
 Low-level echoes from pus or debris may fill the abscess cavity
 Indistinct margins/Capsule ill-defined at first but later may develop
identifiable thick rim.
 Gas in Hypo echoic/ Cystic mass strongly suggest Abscess.
 Gradual resolution of the abscess can be monitored with ultrasound.

 May be single or multiple
 Serial US examination is essential in following the evolutions of an abscess

Cont’d
• Best diagnostic clue: Well-defined hypoechoic area
with irregular wall and internal debris
• Location: Single> multiple; unilateral> bilateral
• Round or thick/smooth-walled complex cystic mass
• Anechoic/hypoechoic ±weak acoustic enhancement
• May contain echogenic internal debris
• Internal echogenic foci with "comet-tail" may
represent gas-forming organisms within abscess
• ±Internal septations or loculations
• ±Renal sinus obliteration or calyceal effacement
• ±Calculus or hydronephrosis
Abscess in the LK containing low-levell echoes
from pus. The abscess capsule is irregular and
thickened.
DDX: infected renal cyst

Pyonephrosis
• Pyonephrosis implies purulent material in an obstructed
collecting system.
• Infected obstructed collecting system.
Depending on the level of obstruction,
• any portion of the collecting system, including the ureter,
can be affected.
• 15% of patients are asymptomatic at presentation.
In the young adult, UPJ obstruction and calculi are the
most frequent cause of pyonephrosis, whereas malignant
ureteral obstruction is typically the predisposing factor in elderly
patients.

Ultrasound finding
• Pyonephrosis :
Grayscale Ultrasound
 Hydronephrosis, with or without hydroureter, in
conjunction with debris within.(Echogenic debris with in collecting
system).
 Most consistent finding: Low level mobile echoes (with or without a fluid-
debris level). (Fluid Fluid level with in collecting system).
 Echogenic pus layering in dependent portion of
collecting system.
 Associated stone or gas may be seen sometimes(Gas with in collecting
system (dirty shadow).
Thickening of urotheliallining of the renal pelvis or
Ureter.

Cont’d

Emphysematous pyelonephritis
 Is a serious necrotizing renal infection.

• Characterized by gas production within renal parenchyma or
perirenal tissues.
• E.coli is the cause in 60-70%
U/S Finding
 Enlarged kidney.
 Ring-down artifacts .low level posterior dirty acoustic
shadowing.
 High amplitude echo with in renal parenchyma.
 : bright foci of gas within parenchyma, peri renal tissue
• CT: may be recommended if the gas obscure renal anatomy.
Cont’d

Xanthogranulomatous pyelonephritis
• Is a chronic granulomatous process from atypical immune
response to subacute bacterial infection.
• Is rare chronic inflammatory condition associated with chronic
obstruction.
• May affect part or entire kidney
• Result in cavitations, fibrosis and chronic granuloma.

Xanthogranulomatous pyelonephritis
• Chronic renal inflammation usually associated with long-
standing urinary calculus obstruction (75%)
• Characterized by destruction and replacement of renal
parenchyma by lipid-laden macrophages.
• Manifested either diffusely (> 80%) or focally« 20%)
• Diffuse: Due to obstruction at ureteropelvic junction.
• Focal or segmental: Due to obstruction of single infundibulum
or one moiety of duplex system.
• Three stages of XGP: Intrarenal ~ perirenal ~perinephric
±retroperitoneal involvement.

Cont’d
Ultrasound findings of diffuse XGP include
 Renal enlargement,
 Hypo echoic mass :Abscess(increased sound transmission)
Granuloma (Decreased sound transmission)
 Maintenance of a reniform shape and
 lack of corticomedullary differentiation.
 Multiple hypo echoic areas correspond to dilated calices or
inflammatory parenchymal masses

Cont’d
• Diffusely enlarged kidney; highly reflective central echocomplex
containing calculus.
• Anechoic or hypoechoic round masses replacing normal parenchyma.
• Echogenicity depends on
amount of debris and necrosis within masses.
• Contracted pelvis due to fibrosis
• Parenchymal thinning ± hydrocalyces
• Segmental XGP: Anechoic or hypoechoic masses surrounding calculus-
obstructing calyx
• Perinephric inflammatory tissue ± fluid collection
• Pyonephrosis, pus-filled calyces or renal abscesses may be
present

Cont’d

Renal Tuberculosis
• Urinary tract tuberculosis (TB) occurs with hematogenous
seeding of the kidney by Mycobacterium tuberculosis from an
extra urinary source (typically lung).
• Urinary tract TB usually manifests 5 to 10 years after the
initial pulmonary infection.
• Urinalysis findings suggestive of urinary tract TB include
 sterile pyuria,
 microscopic hematuria,
 and acid pH

Cont’d
Ultrasound finding
o Mass lesion in renal parenchyma of mixed echogenecity with
or without necrotic area or calcification.
o Mucosal thickening and stenosis of calyx
o Mucosal thickening of renal pelvis and ureter
o Ureteral stricture and hydronephrosis
o Bladder change: mucosal thickening and reduced capacity.

Diffuse renal disease and renal failure
Acute renal failure
 Increase in overall renal size
 Diffuse alteration in the renal echogenicity
 Hypo-or hyperechoic compared with normal.
 Either increased or decreased corticomedullary differentiation

ma
Acute renal failure demonstrating an enlarged,

diffusely hyperechoic kidney with loss of
corticomedullary differentiation.

Acute renal failure in paracetamol overdose. The
kidney is large (16 cm) and hyperechoic with increased
corticomedullary differentiation.

In chronic renal failure
The kidneys shrink and the cortex thins
 The end-stage kidney can be quite tiny and
hyperechoic and may be difficult to differentiate from
the surrounding tissues.
 Both of the kidneys are affected usually.

i ii
Chronic renal failure. The kidney is shrunken with only a

thin rim of cortical tissue remaining. The cortical rim may
be of normal echogenicity (i) or hyperechoic (ii). The
lattersituation is more common.

MEDICAL GENITOURINARY
DISEASES
Assignment
• Acute Tubular Necrosis
• Acute Cortical Necrosis
• Glomerulonephritis
• Diabetes Mellitus
• Amyloidosis

Renal parenchymal disease
• Introduction
 Renal parenchyma diffusely affected-various causes
 Varying degrees of renal impairment seen
 In acute renal failure-U/S to exclude obstruction

For other causes ;clinical situation, biochemical findings

...
• Some disease affect only the cortex
• Other affect primary the medullla
• some affect the parenchyma as a whole

1) Renal size and overall appearance
A) Acute Disease
Swelling may bee seen
Size of the kidney within normal limits in most cases
B) Chronic Disease
Kidney tends to decreases in size
Kidney become echogenic

II) cortex
 May bee seen within normal limits or show an abnormal
increase or decrease in echopattern
 Cortical calcification may occur but less frequent than
medullary calcification

III) medulla/pyramids
 In acute cortical disorder pyramids may more visible-due to
increased cortical echogenicity
 In other cases there may be decreased corticomeduallary
differentiation
 Pyramids enlarged and hyperechoic-in acute tubular necrosis
 Pyramids show increased echogenecity in nephrocalinosis

IV) Renal sinus
• Usually not affected in diffuse parenchymal disease
o may be reduced when parenchyma enlarged
o enlarged in parenchymal atrophy
o collecting system are more prominent in case of
ureteric obstruction

Cortical disorders
A) Glomerulonephritis
 May be due to inflammatory or non-inflammatory
 Many cases have autoimmune component
• Glomerulonephritis can be caused by numerous mechanisms:
● Immunologic mechanisms, for example in systemic
lupus erythematosus (SLE) or acquired
immune deficiency syndrome (AIDS)
● Metabolic disorders, for example diabetes
● Circulatory disturbances, for example atherosclerosis
or disseminated intravascular coagulation
(DIC).
 Clinically: hematuria,proteinuria and variable renal impairment

Cont’d
• Ultrasound finding,
• Both kidneys are affected; the size of the kidneys may be
normal, but renomegaly is often encountered.
• The echo pattern of the cortex is altered; renal cortex may be
 normal,
 echogenic, or
• hypoechoic, but the medulla is spared.
• In acute cases kidney may show some enlargement and
decreased corticomeduallary differentiation
• And shrink if chronic disease develops

Ultrasound appearance of glomerulonephritis
• There are no specific features

• In many cases kidney appear normal
• In some cases variable increased cortical echogenecity

Loss of CMD in glomerulonephritis
B. Acute interstitial nephritis
• Usually result from immunologically induced hypersensitivity
• Rarely associated with sarcoid, systematic lupus eryhematosus or

malignancy
• On U/S; kidneys may normal or enlarged
cortical echopattern increased or normal
A markedly increased parenchymal echopattern in patients with

ARF raise the possibility of AIN
N.B the finding on U/S is nonspecific

Diffusely enlarged in patients with acute interstitial
nephritis

C) Acute cortical necrosis
 Acute cortical necrosis (ACN) is a rare cause of acute
renal failure resulting from ischemic necrosis of the cortex with

sparing of the medullary pyramids
 Classically associated with abruptia placentae or post partum
hemorrhage
 Also occur in shock,sepsis,snake bites and exposure to toxins
 There is micro-vascular thrombosis-cortical ischemia

Cont’d
• The exact etiology is uncertain, although it is likely
• related to a transient episode of intrarenal vasospasm,
• intravascular thrombosis, or glomerular capillary endothelial
damage.
• Ultrasound finding, the renal cortex is initially
Hypoechoic after period of time both kidneys atrophy and the
cortex may calcify.
• U/S:loss of CM differentiation and ill-defined patchy areas
of increased echogenecity in parenchyma with peripheral
perfused area –hypoechoic subcapsular zone

A kidney with acute cortical necrosis showing generally
increased echogenecity with a thin rim of perfused
parenchyam(arrow)

D) Cortical nephrocalsinosis
• Is rare compared to medullary neophrocalcinosis
Focal calcification may occur following trauma, infraction and
infection
Diffuse calcification may occur in acute cortical necrosis and rarely
with chronic glomerulonephritis

Disorders of medullary/pyramids
A. Acute tubular necrosis

 Is one of the most common cause for ARF
 Usually due to cellular ischemia and direct tubular epithelial cell injury induced
by nephrotoxins
 On U/S: diffuse swelling of kidneys
prominent medullary pyramids
some increase in cortical echo pattern with preserved CM differentiation

B .Nephrocalcinosis
• Caused by parathyroidisim and tubular acidosis
Calcification is mainly within medulla
U/S: region of increased echogenecity within medulla
hyerechogenic medulla may be seen in patients with gout

RENAL TRACT CALCIFICATON
 Calcification within the kidney usually occurs in the form of
stones.
 Smaller foci of calcium, which do not shadow on ultrasound,
are associated with conditions such as tuberculosis,
xanthogranulomatous pyelonephritis, nephrocalcinosis or some
neoplastic tumours.

Renal calculi
 Renal calculi may be present in patients with acute renal colic
and complete or partial obstruction of the ipsilateral renal
tract.
 May cause haematuria or UTI.

The common types include:
Calcium stones are the most common
 Struvite (triple phosphate) are associated with UTI .
They may form large, staghorn calculi.
 Uric acid stones associated with gout.
 Cystine stones are the rarest of all and result from cystinuria.

sonographic appearance
 Careful scanning with modern equipment can identify over
90% of renal calculi.
 Highly reflective and displays distal acoustic shadowing.
 Small stones may be missed on ultrasound.
 Obstructed proximal to the stone-hydronephrosis.

(A) A calculus within the PCS of the RK. (B)
A staghorn calculus fills the
Distal acoustic shadowing is easily seen. entire PCS of the kidney. this is,
in fact, a single calculus

Cont’d

Nephrocalcinosis
 Deposition of calcium in the renal parenchyma.
 It is most often related to the medullary pyramids and is
frequently Associated with medullary sponge kidney .
 May also be seen in papillary necrosis, disorders of calcium
metabolism, E.G. Primary Hyperparathyroidism.

Ultrasound appearances
 Nephrocalcinosis may affect some or all of the pyramids.
 Hyper echoic pyramids are seen which may shadow if large calcific foci.
 Less frequently ,calcification is seen in the renal cortex.
 N.B Hyperechogenic medullae are not always the result of
nephrocalcinosis and may bee seen in patients with gout

(A) Nephrocalcinosis, demonstrating deposists of
calcium within the renal pyramids which are
too small to cast an acoustic shadow.
(B) Calcification in the renal pyramids with strong
acoustic shadowing.
ENTITIES THAT MIMIC RENAL CALCULI
 Intrarenal gas
 Renal artery calcification
 Calcified sloughed papilla
 Calcified transitional cell tumor
 Alkaline-encrusted pyelitis
 Encrusted calcification of ureteric stent

Renal cysts and Cystic Renal disease
 Simple renal Cysts
 Autosomal dominant (adult) polycystic kidney disease
 Autosomal recessive (infantile) disease
 Acquired cystic disease
 Multi cystic dysplastic kidney (MCDK)

Simple renal cysts
 The most common renal mass.
 Found in up to 50% of the population,
 The incidence increasing with age.

 Most cysts are asymptomatic
 May be solitary or multiple.
 Generally they are peripheral but may occur within the kidney
adjacent to the renal pelvis.

Cont’d
 A simple renal cyst forms about 65-70% of focal changes
of the kidney.
 With ageing, the cysts usually grow.
 Up to 40% of adult patient show at least one simple
kidney cyst.

Sonographic criteria
I. Anechoic
II. Sharply marginated ( well defined interface with renal parenchyma).
III. Smooth walls
IV. Good through transmission
N.B. Presence a thin single septation or a minor indentation of wall, do not
significantly affect the Dx.
Cysts arising near renal pelvis may some times simulate a dilated Collecting system.

.

Complex renal cysts
These complex renal cysts may contain complex
 fluid,
 septations,
 Thick wall
 calcification, perceptible defined wall, or mural nodularity.
 Irregularity at base of the cyst.

Multiple renal cysts
 With increased use of CT, US, and MRI, patients who
are harboring multiple simple cysts or lesions too
small to characterize are being seen with increasing
frequency.

Cont’d
Multiple renal cysts can be seen in:

 Polycystic kidney disease
 Acquired cystic kidney disease associated with dialysis
(ACKDD), and
 Multi cystic dysplastic kidney.

Autosomal dominant (adult) polycystic kidney disease
ADPKD) the most common hereditary renal disorder and has

no gender predilection.
 The third most common systemic hereditary condition
accounts for 10% to 15% of all patients on dialysis .
 Results in a large number of bilateral cortical
and medullary renal cysts.
 The cysts may vary in size and are often asymmetrical.
 Renal failure develops in 50% of patients
 usually present by 60 years of age.
Cont’d
Clinical feature:
• Flank pain
• Presence between 20 and 39 year.
• Hypertension
• Renal insufficiency
• Renal stone
• Hematuria

Cont’d
 Complications of ADPKD include
• Infection,
• Hemorrhage,
• Stone formation, cyst rupture, and obstruction.
• Stone formation tends to occur in
patients with more and significantly larger cysts.

 Early signs of the disease include hypertension and
flank or back pain with variable progression to ESRD
 Extra renal manifestations of ADPKD include
hepatic >pancreatic>Brain>spleenic cysts>ovaries>testes

 The vascular abnormalities and cyst development are
related to a basement membrane defect.

Ultrasound appearances
 The disease is always bilateral.
 Multiple cysts of various sizes, many having irregular

margins.
 There is often little or no demonstrable normal renal tissue
and the kidneys may become so large that they visibly distend
the abdomen.

Autosomal recessive (infantile) polycystic
kidney disease (PCKD)
 often be diagnosed prenatally on ultrasound.

 The disease carries a high mortality rate in early childhood,
and is therefore rarely seen on ultrasound in children.
 Tiny cysts replace both kidneys, giving them a
hyperechogenic appearance due to the multiple reflections .

Cont’d
Ultrasound appearance
• Lack of corticomedullary differentiation
• Enlarged kidney,
• Echogenic kidneys due to multiple tiny cyst reflection.
• Occasionally, macroscopic cysts will be noted.

Newborn who has bilaterally enlarged, echogenic kidneys
consistent with ARPKD. The right kidney
(A) measures 10 cm in length and the left kidney (B) measures 9.8
cm in length.
Multicystic Dysplastic Kidney Disease (MCDKD)
 Multicystic Dysplastic Kidney disease goes back to a missing
connection between Metanephros and Wolffian duct.
 This can take place either partially, where multicystic
dysplastic focal modifications appear, or generally.
 In that case, the whole system of the kidney shows cystic
degeneration.

Cont’d
• The exact pathogenesis is obscure.
• However, 90% of cases are associated with some form of
urinary tract obstruction during embryogenesis.
• a nonhereditary developmental anomaly also known as
renal dysplasia, renal dysgenesis, and multicystic kidney.

 This is a congenital malformation of the kidney, in which the renal tissue is
completely replaced by cysts.
 It is frequently diagnosed prenatally (although it is naturally a lethal condition if
bilateral).
 Contralateral renal hypertrophy is often present.
 MCDK occurs as a result of severe early renal obstruction during
development in utero.
 Obstructed calyces become blocked off,
 forming numerous cysts which do not connect.

Cont’d
Ultrasound findings of MCKD include:
 The kidney is small, malformed, and
composed of multiple cysts with little, if any normal renal
parenchyma.
 Multiple non communicating cysts,
 Absence of both normal parenchyma and normal renal
sinus, and
 Focal echogenic areas representing primitive mesenchyma
or tiny cysts.

Cont’d
• Small, malformed
kidney containing
multiple cysts.

Medullary cystic disease
 characterized by small cysts at the corticomedullary junction
and medulla.
 Present in children or young ,usually with sign of renal failure
(ESRD).
 Kidney small, echogenic with small cysts(0.1 to 1cm)
 Patients present with polyuria, salt wasting, and
ultimately ESRD

Cont’d
• A multiple cyst on renal
medulla.

GENITOURINARY TUMORS
 Benign Focal Tumours

• Renal cyst
• Oncocytoma
• AML
• Renal adenoma
 Malignant tumor
• RCC
• Whilms tumor

Benign Focal Tumors
A. Angiomyolipoma
 homogeneous, highly echogenic, usually rounded lesion in the renal
parenchyma.
 Tumor echogenicity depends on its constituents .
Fatty tissue
Smooth muscle
Blood vessels
 usually solitary, asymptomatic lesions, found incidentally on the scan.
 tend to be smaller and more echogenic than RCC, and may demonstrate
shadowing.
 CT is -identify the fat content of the lesion
Cont’d
Longitudinal transabdominal
ultrasound depicts a large hyperechoic
AML with focal shadowing AML,distorting renal sinus complex.
.

B. Oncocytoma
• This is a benign tumor which usually shows more echo than
the kidney cortex and is of a mostly homogenuous structure.
Ultrasound appearance
 Well defined
 Solid mass
 Homogenous
 Hypo to iso echoic and hyper echoic central scar.

Cont’d
 The occurance of scars located at the centre is
quite common

Cont’d

Cont’d

C. Renal adenoma
 usually a small, well-defined hyperechoic lesion, similar in
appearance to the angiomyolipoma.
 It is felt that adenomas are frequently early manifestations of
renal cas.
 Most incidentally discovered, small (less than 3 cm),
parenchymal renal masses are slow-growing and may be
safely monitored with CT or ultrasound, particularly in the
elderly.

Cont’d

C. Malignant renal masses
 Ultrasound highly sensitive in detecting large renal masses
above 2.5 cm in diameter.
 Smaller masses may be missed as they are isoechoic (in 86%
of cases).

Renal cell carcinoma (RCC) (Adenocarcinoma)
 most common type of renal malignancy

 Malignant renal tumor arises from tubular epithelium.
 RCCs are frequently large at clinical presentation.
The classic diagnostic triad of
• flank pain,
• gross hematuria, and
• palpable renal mass was seen in only 4% to 9% of
patients at presentation.
Systemic symptoms (e.g., anorexia, weight loss) were
common with advanced disease.

Renal cell carcinoma (RCC) (Adenocarcinoma)
 Can be identified as an incidental finding in an asymptomatic patient
 Most common appearance: Hyper echoic and vascular
 Small tumors are usually hyperechoic; simulate AML.
 Large tumors tend to be hypoechoic, exophytic with anechoic necrotic
areas.
 Large, heterogeneous mass which deforms the shape of the kidney.
 May contain areas of cystic degeneration and/or calcification.

Cont’d

Cont’d
• Longitudinal
transabdominal ultrasound
shows a small RCC. The
tumor is hyperechoic
relative to the renal
parenchyma and has a
hypoechoic
"pseudocapsule" ~ typical of
RCC

• ransabdominal ultrasound
shows a large exophytic
hyperechoic RCC .
• Note that the mass is well-
defined, with areas of
necrosis ~ compressing on
the collecting system.

• Longitudinal trans
abdominal ultrasound
shows a large lower pole
RCC with central necrosis ~.
Note that a cystic
component, due to
necrosis, is common in RCC

RCC

Cont’d
. .
• Renal cell carcinoma with
both cystic and solid
component.

Wilm’s tumour
 Is the commonest abdominal tumour in
neonates.
 Present as abdominal mass
 On ultrasound;
a solid renal mass, echogenic with small cysts.

Cont’d

Pelvicalyceal System Dilatation And Obstructive Uropathy
• Introduction
 The pelvicalyceal system and ureter transport urine from
collecting tubules in the medullary pyramids to the bladder.
 Renal pelvis and calyces lie in the center of kidney surrounded
by fat of renal sinus.

Cont’d
 Functional obstruction- no fixed narrowing despite
elevated pressures proximally. eg PUJ obstruction
 An anatomical obstruction is caused by a fixed
point of narrowing in the urinary tract.

.

Cont’d
Physiological dilatation.
 Mild dilatation of PCS
 over-distended bladder.
 An external renal pelvis.
 Pregnancy -more frequently on the Rt.
 If symptomatic, the suspicion of obstruction in a dilated
system is increased

Obstructive Uropathy
 US plays a prominent role in diagnosing obstruction.
 dilatation of the collecting system occurs proximal to the

site of obstruction .
 If the obstruction is long-standing the renal cortex may
atrophy, becoming thin.
 Normal thickness of cortex is a good prognostic indicator.
 May cause renal failure

Causes of renal tract obstruction

Causes of renal tract obstruction

hydronephrosis

Cont’d

Mild(grade I ) hydronephrosis
• Calyceal dilatation (anechoic area within renal sinus)
• Maintains normal anatomic structure
N.B Normal finding in overhaydrated patient, or over distended
bladder

Mild hydro

Moderate(grade II) hydro
Calyceal system becomes distended .

Severe (grade III) hydro
Effacement of renal medulla & cortex.

Cont’d

Non-obstructive hydronephrosis
 Not all renal dilatation is the result of an obstructive

process and the kidney may frequently be dilated for other
reasons.
Reflux
 is normally diagnosed in children.
 is associated with recurrent UTI and can result in reflux
nephropathy, in which the renal parenchyma is irretrievably
damaged.
 dilatation of the ureters at the bladder base, due to the
retrograde passage of urine.

O
qu i t
ever g ! !
N a d in
Re

Renal Ultrasound

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Renal Ultrasound

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Chapter 6

Renal Tract Ultrasound

9/5/22 Minishir S (MRT) 1

9/5/22 Minishir S (MRT) 2

• Recognize and describe normal renal sonographic anatomy and

• Identify focal and diffuse lesions of the kidneys on sonography.

• Recognize and describe the sonographic appearance of selected diseases.

9/5/22 Minishir S(MRT) 3

• Superoinferior axes=lower ends lying more anteriorly

• Mediolateral axes=anterior surface face

anterolaterally & posterior surface posterolmedially.

 Even though they are protected

by thoracic ribs, they are not in

the thoracic cavity because they

are below the diaphragm.

9/5/22 Minishir S(MRT) 5

9/5/22 Minishir S(MRT) 6

Classification of a mass (Solid V's cystic)

Post surgical complications

Follow-up of previously identified pathology

Guidance of aspiration, biopsy or intervention

9/5/22 Minishir S(MRT) 7

Cortex at least as hypoechoic as the liver

9/5/22 Minishir S(MRT) 8

No special preparation unless bladder is wanted

First examined on supine position then decibutus.

3.5MHz for adults & 5MHz for children

9/5/22 Minishir S(MRT) 9

Apply coupling agent

Use liver as acoustic window on the RT side

Scanning-longitudinal and transeverse

- coronal- lt or rt lateral decubitus.

9/5/22 Minishir S(MRT) 10

9/5/22 Minishir S(MRT) 11

9/5/22 Minishir S(MRT) 12

9/5/22 Minishir S(MRT) 13

9/5/22 Minishir S(MRT) 14

Upper abdominal transverse scan, Rt side

9/5/22 Minishir S(MRT) 15

9/5/22 Minishir S(MRT) 17

Length: craniocadual (find the longest length and

9/5/22 Minishir S(MRT) 19

 Renal Capsule- echogenic, surrounds cortex of the kidney.

 Cortex- less echogenic than liver and spleen, homogeneous

 Medulla- pyramids found here, hypoechoic to anechoic

 Arcuate Arteries- echogenic dots found at the corticomedullary

 Sinus- hyper echoic

9/5/22 Minishir S(MRT) 20

Contains renal corpuscle & proximal and distal

Filtration takes place

9/5/22 Minishir S(MRT) 21

located between capsule & medulla

 Low level uniform echoes

 Less echogenic than liver & spleen

 Columns of Bertin = columns of cortical tissue located between pyramids

o can enlarge & mimic a mass

• Indentation of renal sinus laterally

9/5/22 Minishir S(MRT) 23

o 8-18 medullary pyramids

o Reabsorption takes place

9/5/22 Minishir S(MRT) 24

9/5/22 Minishir S(MRT) 25