Ultrasound of the Abdomen part I - PowerPoint Presentation

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Ultrasound of the Abdomen part ILecture 10Urinary Tract II

Holdorf

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Outline

Acquired cystic disease

Medullary sponge kidney

Von Hippel-Lindau Disease

Angiomyolipoma

Tuberous sclerosis

Renal cell carcinoma

Renal metastases

Wilm’s Tumor

Acute pyelonephritis

Chronic Pyelonephritis

Xanthogranuomatous Pyelonephritis

Pyonephrosis

Mycetoma

Acute renal failure

Renal artery thrombosis

Renal vein thrombosis

Acute tubular necrosis

Acute glomerulonephritis

Hydronephrosis

Nephrocalcinosis

Papillary necrosis

Renal sinus lipomatosis

Urinary bladder

Ureters

Ureteral anomalies

Transitional cell carcinoma

Renal vascular ultrasound

Resistive index

Renal artery stenosis

Renal transplantation

Laboratory values

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Acquired cystic diseaseDevelopment of multiple cysts in chronically failed kidneys during long-term hemodialysis.Hemorrhage often occurs into these acquired renal cysts, resulting in pain and hematuria.

These cysts do not function.

Associated with an increased incidence of renal cell carcinoma.

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Acquired Cystic Disease

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Medullary Sponge KidneyCongenital dysplastic cystic dilatation of the medullary pyramids due to tubular ectasia or dysplasia. Ectatic collecting tubules may be seen on excretory urography.

Due to urinary stasis, calcium deposits form in these dilated tubles.

Sonographically, these calcium deposits appear as hyperechoic medullary pyramids.

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Medullary Sponge Kidney

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Von Hippel-Lindau DiseaseInherited disease which usually presents in the second to third decade of life with serious visual impairment.

Although Von Hippel-Lindau syndrome is characterized by retinal and central nervous system hemangioblastomas, sonographers need to be aware of other related tumors that can be found while performing a complete abdominal evaluation such as:

Renal cell carcinomas

Pheochromocytomas

Islet cell tumors

Renal and pancreatic cysts

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Von Hippel-Lindau Disease

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AngiomyolipomaHyperechoic benign renal tumor. Its echogenicity is greater than or equal to that of the renal sinus.

A propagation speed artifact may result in the posterior displacement of structures due to slower acoustic velocity in this fatty mass.

CT confirmation of fat in an echogenic renal mass is considered diagnostic of Angiomyolipoma.

80% involve the right kidney.

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Angiomyolipoma

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Tuberous SclerosisA multi-system genic disease that causes benign tumors to grow on organs such as the brain, kidneys, heart, eyes, lungs and skin. It commonly affects the central nervous system.

The kidneys are the main focus of an abdominal sonographic evaluation in a patient with tuberous sclerosis. Patients with tuberous sclerosis have an increased incidence of renal cysts and Angiomyolipoma. Angiomyolipomas are typically bilateral in patients with tuberous sclerosis.

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Tuberous Sclerosis-MRI of patient with Angiomyolipoma

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Renal Cell CarcinomaMost common solid renal mass in the adult. Typically, it appears as a unilateral encapsulated mass. Nephrectomy is commonly recommended.

Sonographically, it is hypoechoic relative to the normal adjacent renal parenchyma.

Common presenting symptoms include:

Hematuria (most common)

Flank pain

Palpable mass

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Tumor extension into the renal veins and inferior vena cava is common.The lungs are the most common site of distant metastases. Lymph nodes, liver, bone, adrenal glands, and the contralateral kidney are also metastatic sites.

Increased incidence associated with:

Acquired cystic disease (chronic Dialysis)

Von Hippel-Lindau Syndrome

Tuberous sclerosis

APKD

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Renal Cell Carcinoma

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Renal Cell Carcinoma

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Renal metastases To the kidneyRenal parenchyma may be the site of secondary tumors that have metastasized from other primary organs (such as the lung, breast, colon, etc…)

Malignant cells from leukemia and lymphoma can metastasize to the kidney.

Sonographically presents as:

Hypoechoic masses of

Diffusely enlarged inhomogeneous kidney.

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Renal Metastases To the kidney

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Wilm’s tumorWilm’s tumor (nephroblastoma) is the most common CHILDHOOD renal tumor.

Mean age at diagnosis is 3.5 years.

Patients typically present with a large asymptomatic flank mass. Other symptoms include:

Hypertension

Fever

Hematuria

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Metastasis can be seen to the lungs, bone, lymph nodes, and retroperitoneum.90% survival rate with chemotherapyTumor extension can be seen into the renal vein and IVC.

Wilm’s tumors must be differentiated from adrenal neuroblastomas. Wilm’s tumors destroy the renal contour. If normal renal contour is maintained bilaterally, the abdominal mass is most likely an adrenal neuroblastoma.

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Pediatric Cancer IncidenceLeukemia (ALL) 35.0%CNS tumors 16.6%Lymphoma 15.0%

Neuroblastomas 7.8%

Soft tissue sarcomas 7.4%

Wilm’s tumors 6.3%

Bone 6.0%

Hepatic Tumors 1.1%

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Wilm’s Tumor

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Acute PyelonephritisMost renal infections occur via an ascending route from the bladder. They are usually caused by bacteria from the intestinal tract.

Imaging studies are often unnecessary because the diagnosis of Pyelonephritis can be made clinically.

Ultrasound findings include:

Renal enlargement

Hypoechoic parenchyma

Absence of sinus echoes

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When acute Pyelonephritis is focal, it is called acute focal bacterial nephritis or lobar nephronia. Sonographically, this appears as a focal wedge-shaped area or a hypoechoic renal lobe. A similar appearance can be seen in focal ischemia and renal infarction.

Emphysematous Pyelonephritis is a bacterial infection associated with renal ischemia. More commonly occurring in diabetics. Immunosuppressed patients and patients with urinary tract obstructions. Bacteria produce inrarenal gas causing reverberation or comet-tail artifacts. Nephrectomy is usually required to treat infection.

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Acute Pyelonephritis

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Acute focal bacterial nephritis

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Chronic PyelonephritisRenal injury induced by recurrent renal infection due to:

Anatomic anomalies

Obstructive lesions

Ureteral reflux

Sonographically, chronic Pyelonephritis leading to end-stage renal disease appears as a small hyperechoic kidney with cortical thinning.

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Chronic Pyelonephritis

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Chronic Pyelonephritis

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Xanthogranulomatous Pyelonephritis (XGPN)Type of chronic phelonephritis resulting from chronic infections due to a long term obstruction.

Associated findings include:

Renal enlargement

Parenchymal abscesses

Staghorn calculus

Papillary necrosis

Hydronephrosis

Pyonephrosis

Loss of cortical-medullary boundary

Cortical thinning

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Failure to depict a normal kidney associated with a staghorn calculus suggest the diagnosis of XGPH

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Staghorn Calculus cartoon

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Staghorn calculus

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PyonephrosisPurulent material in the collection system of the kidney associated with an infection secondary to renal obstruction.

Percutaneous or surgical drainage is required for adequate treatment.

Ultrasound findings include hyperechoic debris in a dilated renal collecting system.

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Pyonephrosis

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Mycetoma (Fungal Ball)Candidiasis is the most common renal fungal disease. Fungal infections result from hematogenous seeding or ascending from the bladder.Fungus balls appear as hyperechoic, non-shadowing masses.

Hematogenous =

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Mycetoma (Fungal Ball)

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Hyperechoic Renal MassesMycetomaAngiomylipomasBlood clots

Pyogenic debris

Renal stones

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Acute renal failure (ARF)Reduction in glomerular filtration rate (GFR) resulting in an increase in blood nitrogen waste.Three main mechanisms of ARF:

Prerenal failure (decreased perfusion)

Hypotension

Hypovolemia = Decreased blood volume

Cardiac failure

Renal artery stenosis (bilateral)

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The glomerulus and its function

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Intrinsic (intrarenal) renal failure acute tubular necrosis (most common) glomerular diseases (Nephritic syndrome)

Interstial nephritis (Drugs or Contrast agents)

Autoimmune disease

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Ultrasound’s role in diagnosing the cause of acute renal failure is to determine:Hydronephrosis (indicates post-renal failure)Abnormal resistive index (<0.7)

Distinguishing the cause is important in relieving obstruction and in facilitating appropriate treatment of other renal medical disease. Prompt intervention prevents loss of renal parenchyma.

Laboratory studies used to evaluate ARF:

Urine output

Urinalysis

Blood urea nitrogen (BUN)

Serum creatinine

Changes in serum creatinine reflects changes in glomerular filtration rate, and is the most accurate method of determining ARF.

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Renal function and Blood Pressure: What’s the connection?How does high blood pressure hurt the kidneys?

High blood pressure makes the heart work harder and, over time, can damage blood vessels throughout the body. If the blood vessels in the kidneys are damaged, they may stop removing wastes and extra fluid from the body. The extra fluid in the blood vessels may then raise blood pressure even more. It's a dangerous cycle.

High blood pressure is one of the leading causes of kidney failure, also called end-stage renal disease (ESRD). People with kidney failure must either receive a kidney transplant or have regular blood-cleansing treatments called dialysis. Every year, high blood pressure causes more than 25,000 new cases of kidney failure in the United States.

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Renal Artery ThrombosisRenal artery thrombosis (occlusion) is a sudden cause of prerenal failure that presents as:Acute flank pain

Hematuria

Sudden rise in blood pressure

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Renal Artery Thrombosis/stenosis

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Renal Vein thrombosis Associated with

Extrinsic compression

Nephrotic syndrome

Renal tumors

Renal transplants

Trauma

Sonographic findings include:

Dilated thrombosed renal vein

Absent intrarenal venous flow

Enlarged hypoechoic kidney

High-resistance renal artery waveform (reversal of diastolic component)

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High-resistance renal artery waveform

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Low resistance RA Waveform

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Acute Tubular NecrosisATN is the most common cause of medical renal disease or intrinsic (intrarenal) acute renal failure.

ATN results from prolonged ischemia or the exposure of nephrotoxins (drugs or contrast agents) causing damage to the tubular epithelium of the nephron leading to acute renal failure.

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Acute Tubular necrosis can be reversible.Sonographic findings include:Renal enlargementIncreased resistive index (RI) (>0.7)

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Acute Glomerulo-nephritisAcute glomerulo-nephritis is an inflammatory response resulting to glomerular damage caused by an autoimmune reaction, infection or exposure to toxins.

Presenting symptoms include:

Sudden onset of hematuria

Proteinuria

Azotemia: High concentrations of urea and creatinine (among other nitrogen containing compounds) in the blood.

RBC casts in urine.

Sonographic findings

Renal enlargement

Increased resistive index (RI)

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HydronephrosisDilatation of the renal pelvis and calyces.The normal renal sinus is a central echogenic area composed of peripelvic fat, renal vessels, lymph nodes and collecting structures. Hydronephrosis produces a separation of the normal sinus echogenicity by an anechoic urine collection.

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Hydronephrosis

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Hydronephrosis: Severe

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Hydronephrosis: Moderate

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Hydronephrosis: mild

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If untreated, hydronephrosis secondary to obstruction can lead toHypertensionLoss of renal functionSepsis

Common causes include

Calculi

Benign prostatic hypertrophy (BPH)

Prostate cancer

Pelvic malignancies

Pregnancy

Uretero-pelvic junction obstruction

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Three common areas of obstruction by a stone:Uretero-vesical junction (Most common)Ureteropelvic junctionPelvic brim

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Common sites of kidney stones

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Blockage in the UPJ

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Uretero-vesical junction

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Obstructive nephropathy is also diagnosed by evaluating the intrarenal vascularity. A threshold resistive index (RI) of greater than 0.7 is suggestive of obstructive hydronephrosis.

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Nephro-calcinosisDisorders of calcium metabolism (hypercalcemia and hypercalciuria) that result in the formation of calcium renal stones and deposition of calcium salts in the renal parenchyma.

Nephrolithiasis (renal stones) arise in the collecting system. The main symptom of renal stones is acute back or flank pain often radiating down to the ipsilateral groin. When severe, this can be accompanied by fever, chills, dysuria, cloudy urine and hematuria.

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Causes of Nephrocalcinosis HyperparathyrodismVitamin D intoxication (too much)Malignancies

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Nephrolithiasis-Renal Stones

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Nephrolithiasis-renal stones 20 month neonate

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Papillary NecrosisIschemia of the medullary pyramids. Clinical diagnosis can be made by identifying sloughed papilla in the urine. Passage of sloughed papillae can cause pain and urine obstruction.

Papillary necrosis is associated with the following conditions:

Analgesic (painkiller) abuse – most common

Diabetes mellitus

Urinary tract obstruction and infections

Renal vein thrombosis

Sickle cell disease

Chronic heart failure

Cirrhosis

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Medullary (renal Pyramid) Necrosis

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Medullary Necrosis

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Sonographic findings include:1. echogenic material within the collecting system representing sloughed papillae2. triangular cystic collections are seen represent the absence of medullary pyramids

3. Bright echoes produced by the arcuate arteries can be visualized at the periphery of the cystic space.

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Renal sinus lipomatosisIncreased renal sinus fat that replaces normal renal parenchyma.Ultrasound shows an increase in the central sinus echo complex with cortical thinning.

Intravenous urography demonstrates compression of he calyces and renal pelvis by renal sinus fat.

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Renal Sinus Lipomatosis

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Urinary BladderThe urinary bladder is located behind the pubic bone. The apex points anteriorly and is connected to the umbilicus by the median umbilical ligament (urachus). The ureters enter the bladder at the superolateral angle of the trigone and exit the bladder via the urethra.

Normal bladder wall thickness is typically

< 5 mm in a non-distended bladder

< 3 mm in a distended bladder

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urinary bladder wall thickening

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Bladder AnomaliesBladder diverticula are herniations of the bladder mucosa through the bladder wall musculature. They may be congenital or acquired.

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Bladder diverticula

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Urachal CystA urachal cyst is a cystic dilatation of the fetal urachus, which is the medial umbilical ligament connecting the bladder to the umbilicus.This is seen sonographically as a cystic structure superior and anterior to the bladder

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Urachal Cyst

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UretersThe ureters exit the kidney posterior to the renal artery and vein.

At the hilum of the kidney

Vein exits anteriorly

Artery enters between the vein and ureter

Ureter exits posteriorly

Descending inferiorly, the ureters lie on the anterior surface of the psoas muscles. In the pelvis, the ureters cross anterior to the common iliac vessels to insert upon the trigone of the bladder.

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Vein, artery, ureter

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ureters

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Cartoon of the ureters/trigone

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Ureteral anomaliesUreteroceles Appear as a cyst-like enlargement of the lower end of the ureter which projects into the ladder lumen at the uretero-vesical junction.

Ectopic ureteroceles

Are usually associated with a duplex kidney and complete ureteral duplication . The distal ectopic ureterocele results in obstruction of the upper pole collecting system.

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Ureterocele

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Ectopic ureterocele

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Transitional Cell CarcinomaTransitional cell carcinoma (TCC) is the most common bladder neoplasm.The urinary tract is lined with transitional cells. Although transitional cell carcinoma may occur in the bladder, ureters or renal pelvis, it commonly occurs in the urinary bladder.

A mass or focal thickening of the bladder wall should raise the suspicion of a TCC.

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Hydronephrosis may be caused by TCC originating in the ureter.Hematuria is the most common clinical presentation.Other bladder masses include:Cystitis

Prostate cancer

Squamous cell cancer

Blood clots

Pyogenic debris

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Transitional cell carcinoma of the bladder

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Renal Vascular UltrasoundThe normal renal artery demonstrates continuous forward flow during diastole, typical of low resistance blood perfusion.

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Resistive Index (RI)Resistive index is commonly used toEvaluate renal transplant rejection

Access suspected hydronephrosis

Evaluate medical renal disease

Renal dysfunction, caused by a variety of reasons, results in a loss of diastolic flow, thus increased renal arterial resistance.

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RI=Peak systolic frequency (velocity) – end diastolic frequency (velocity) Peak systolic frequency (velocity)

Normal resistive index is typically <0.7 (in real world more like <.08)

Resistive index is a value comparing the amount of diastole to that of systole. It is a relative value (no units) that can be measured in frequency or velocity.

If the RI = 0.5 (diastole is 50% of systole)

If the RI = .07 (diastole is 30% of systole)

If the RI = 1.0 (diastole is absent)

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Normal RI .67

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Abnormal RI

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End stage renal failure/snowball kidney

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Renal Artery StenosisSymptoms of renal artery stenosisSudden onset of hypertension

Uncontrollable hypertension

A hemodynamically significant renal artery stenosis may produce decreased renal size

(< 9cm in length)

Renal artery evaluation methods:

Direct evaluation – Renal artery velocities

Renal artery / Aortic ratio (RAR) > 3.5

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Indirect evaluationParvus Tardus (slow and late)Absent early systolic peakParvus Tardus is defined as a small slow pulse.

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Renal arteries

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Renal stent

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Parvus Tardus waveform

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Renal TransplantationRenal transplantation is the treatment of choice for end-stage renal disease (ESRD). Diabetes is the most common cause of renal disease leading to kidney transplantation.

Pre-transplant evaluation of the living donor is important for screening and surgical planning. Harvesting the left kidney is favored due to its longer renal vein. Multiple renal arteries need to be identified (if present) as this will require additional surgical time.

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The transplanted kidney can be placed on either side of the pelvis. The ureter is attached to the urinary bladder. The arterial anastomosis may be with the external or internal iliac artery.Poor function of the renal transplant may be the result of acute tubular necrosis (ATN) in the immediate post-transplantation period.

Ultrasound is the most common imaging procedure of the renal transplant. It is utilized in accessing:

Immediate surgical complications

Location for renal biopsy

Vascular status in acute rejection.

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Post-transplant complications include:Fluid collections:Hematomas (24 hours post op)Urinomas (24 hours post op)

Abscesses

Renal artery kinking or thrombus

Renal vein thrombosis

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Renal Transplant

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Sonographic findings of acute renal rejection include:Renal enlargement (increased length)Loss of cortical medullary boundary

The resistive index (RI) is used to evaluate arterial flow resistance of eth renal vascular bed.

<0.7 = normal resistive index

0.7-0.8 = questionable transplant dysfunction

>0.8 = transplant dysfunction

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Laboratory valuesUrinalysis: includes the microscopic examination of sediment and qualitative evaluation of protein, glucose, blood, nitrites and white blood cells.

Serum creatinine: serum concentration of creatinine is reversely related to glomerular filtration rate (GFR).

Blood Urea Nitrogen (Bun): is unsuitable as a single measure of renal function because it varies with urine flow rates and production of

ureas

.

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What is medullary sponge kidney?Describe the sonographic appearance of medullary sponge kidney.

What is the most common cause of an abdominal mass in the newborn?

List four sonographic features of multiple dysplastic kidney disease.

What contra-lateral renal abnormalities are found when Multicystic dysplastic kidney disease is unilateral?

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6. What are four sonographic criteria for a simple cyst?7. What three criteria suggest that a cyst is atypical and possibly malignant?

8. Bilateral enlargement of the adult kidney caused by numerous cysts of varying sizes is seen with which disease?

9. Describe the sonographic appearance of infantile polycystic kidney disease.

10.Infantile polycystic kidney disease results in renal dysfunction. What other anomalies are associated with infantile polycystic kidney disease?

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11. Name three anatomic anomalies that appear as pseudo tumors of the kidney.12. What is the term which refers to patients on chronic hemodialysis that develop bilateral renal cysts?

13. What would a Sonographer look for in a patient with a history of tuberous sclerosis?

14 What are other names for a renal cell carcinoma?

15. Renal cell carcinoma is associated with what four disease?

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16. Renal cell carcinoma Sonographically appears as an encapsulated, solid mass that is hypoechoic relative to normal, adjacent renal parenchyma. What additional areas should be evaluated whenever a solid renal mass is detected?

17. What common sonographic artifact is demonstrated with renal Angiomyolipoma, lipoma, and adrenal myelolipoma?

18. What mass should be suspected when a filling defect is noted in the bladder?

19. What is the most common solid tumor in children diagnosed by ultrasound?

20. What are the ultrasound findings associated with significant acute pyelonephritis?