basics of pediatric renal ultrasound...basics of pediatric renal ultrasound xviii international...

Basics of Pediatric Renal UltrasoundXVIII International Ultrasound Course

Mexican Society of Radiology and Imaging

Jennifer Lynn Nicholas, MD, MHA

Assistant Professor

Washington University School of MedicineSeptember X, 2018

Anatomy of a Normal Kidney

source: www.hopkinsmedicine.com

Standard Ultrasound Exam

Normal Size of Kidneys in Children

Han, B.K. and D.S. Babcock, Sonographic measurements and appearance of normal kidneys in children. AJR Am J Roentgenol, 1985. 145(3): p. 611-6.

Kadioglu, A., Renal measurements, including length, parenchymal thickness, and medullary pyramid thickness, in healthy children: what are the normative ultrasound values? AJR Am J Roentgenol, 2010. 194(2): p. 509-15.

RIGHT KIDNEY = 8.1 CM LEFT KIDNEY = 7.8 CM

3 YEARS OF AGE

HEIGHT = 97 CM

WEIGHT = 14 KG

BSA= 6.1 cm^2

Report for Normal Renal Ultrasound

DATE: 3/24/2014

CLINICAL HISTORY: Multiple urinary tract infections. Fever and dysuria.

EXAM: Gray scale and selective Color Doppler imaging of the kidneys and bladder.

COMPARISON: None.

FINDINGS:

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

RIGHT KIDNEY: The right kidney measures 8.1 cm, which is upper normal in length for the patient’s age, height, weight, and body surface area.

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

LEFT KIDNEY: The left kidney measures 7.8 cm, which is normal in length for the patient’s age, height, weight, and body surface area.

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

The right kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

The left kidney is normal in position and contour with normal echogenicity and good corticomedullarydifferentiation.

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

There is no collecting system dilation.

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

BLADDER: The urinary bladder is only distended to a volume of 28 mL, but is grossly normal.

DATE: 3/24/2014

COMPARISON: None.

FINDINGS:

BLADDER: The urinary bladder is only distended to a volume of 28 mL, but is grossly normal. Neither ureter was visualized.

IMPRESSION: Normal sonographic appearance of the kidneys and bladder.

Report with Abnormal Findings

NEWBORN

Case One

RIGHT KIDNEY = 7.5 CM, which is more than two standard deviations above normal

LEFT KIDNEY = 7.4 CM, which is more than two standard deviations above normal

Normal position. Bulbous contour. Increased echogenicity. Loss of corticomedullary differentiation. Multiple cystic structures throughout the parenchyma. The collecting system is not dilated.

Normal position. Bulbous contour. Increased echogenicity. Loss of corticomedullary differentiationMultiple cystic structures throughout the parenchyma. The renal pelvis and a few central calyces are visualized.

Newborn with oligouria

Case One

RIGHT KIDNEY = 7.5 CM, which is more than two standard deviations above normal

LEFT KIDNEY = 7.4 CM, which is more than two standard deviations above normal

Normal position. Bulbous contour. Increased echogenicity. Loss of corticomedullary differentiation. Multiple cystic structures throughout the parenchyma. The collecting system is not dilated.

Normal position. Bulbous contour. Increased echogenicity. Loss of corticomedullary differentiationMultiple cystic structures throughout the parenchyma. The renal pelvis and a few central calyces are visualized.

Newborn with oligouria

AUTOSOMAL RECESSIVE POLYCYSTIC KIDNEY DISEASE

Case One

“Hydronephrosis”

How would you describe these kidneys?

• Hydronephrosis

• Pelvocaliectasis

• Pelviectasis

• Pyelectasis

• Mild/Moderate/Severe

How would you describe these kidneys?

Antenatal Urinary Tract Dilation

Classification Systems

• Urinary tract dilatation in utero: Classification and clinical applications, Radiology 1986, Grignon et al.– Morphologic classification system– Grade 1

• APRPD <10 mm, normal

– Grade 2• Intermediate hydronephrosis, post-natal urology surgery ½ the time

– Grade 3• Intermediate hydronephrosis, post-natal urology surgery ½ the time

– Grade 4 • Moderate dilatation of the calyces, easily identified renal cortex,

surgery required

– Grade 5• Severe dilatation of the calyces, with atrophic cortex, surgery required

SFU grading system

Timberlake MD, Herndon CD. Mild to moderate postnatal hydronephrosis--grading systems and management. Nat Rev Urol. 2013 Nov; 10(11):649-56

Urinary Tract Dilation

Consensus on antenatal and postnatal urinary tract dilation (UTD)

1) unified description of upper tract dilation (pre and post natal)

2) a standardized scheme for the perinatal evaluation of these patients based in sonographic criteria

Classification system looks at

1) Anterior-posterior renal pelvic diameter (APRPD)

2) Calyceal dilation

3) Renal parenchymal thickness

4) Renal parenchymal appearance

5) Bladder abnormalities

6) Ureteral abnormalities

“A” denotes antenatal and “P” denotes postnatal

Consensus on antenatal and postnatal urinary tract dilation (UTD)

– Not designed as definitive final classification system

–Will need to be validated and/or modified with clinical experience and up to date evidence-based research

– Designed to be used in cases of isolated UT dilation

• not for solitary, ectopic, multicystic dysplastic kidneys (MCDK) or other cystic diseases of the kidney

• Not for post-surgical evaluation

Consensus on UTD Recommendations

• Terminology– avoid the use of non-specific terms in describing UT dilation

(e.g. hydronephrosis, pyelectasis, pelviectasis, uronephrosis, UT fullness or prominence, and pelvic fullness)

– Consistently use “UT dilation.”

• Report/communication– Description of the six imaging parameters should be

described in the body of the report and the specific UTDcategory should be in the impression i.e. UTD A1 UTD A2-3, UTD P1, UTD P2, or UTD P3

US parameters used in UTDclassification system

UTD classification

UTD management

Ultrasound appearance of UTD A1. A and B: Fetal kidneys at 19 weeks gestation. anterior-posterior renal pelvis measuring less than 7 mmC and D: Fetal kidneys at 37 weeks gestation. C: anterior-posterior renal pelvis measuring less than 10 mm

Ultrasound appearance of UTD A2-3

Examples

Appearance of normal kidneys on postnatal ultrasound.

A: Imaging in the transverse plane demonstrates an anterior posterior renal pelvis diameter (APRPD) < 10 mm, which is normal for age. Note that the APRPD is measured at the maximal diameter of intrarenal pelvis dilation rather than that of extrarenal pelvis dilation.

B: Imaging in the sagittal plane demonstrates normal renal parenchyma without any calyceal dilation. The bladder is

normal (not shown), and the ureters are not visualized.

A: APRPD 10 to <15 mm. B: central but no peripheral calycealdilation. Renal parenchyma is otherwise normal. C: APRPD <10 mm. D: central calyceal dilation.

UTD P1

UTD P2

A: APRPD 15 mm. B: peripheral calyceal dilation but normal renalparenchymal thickness and appearance. No bladder abnormalities C: APRPD <10 mm. D: peripheral and central calyceal dilation.

UTD P3

A: Imaging in the transverse plane demonstrates an anterior-posterior renal pelvis diameter (APRPD) 15 mm with peripheral calyceal dilation.

B: Imaging in the sagittal plane demonstrates parenchymal

thinning and cysts (arrow).

C: Imaging of the bladder demonstrates increased wall thickness.

Normal Neonatal Kidneys

2-day-old girl

Slightly increased echogenicity of the renal cortex with hypoechoic pyramids is within normal limits for a newborn.

Normal Neonatal Kidneys

1-day-old boy

Slightly increased echogenicity at the bases of the pyramids.

Tamm-Horsfall Proteinsuromodulin

Case One

Enlarged kidneys that are increased in echogenicity with innumerable tiny cysts.

Case One

Case Two

3-year-old with hematuria

Hypoechoic mass in the upper pole of the right kidney.

Case Two

WILMS TUMOR

Case Two

WILMS TUMOR

Case Three

3-month-old with flank mass

Multiple cysts of varying sizes that do not communicate with each other.

No appreciable normal renal parenchyma.

Case Three

3-month-old with flank mass

MULTICYSTIC DYSPLASTIC KIDNEY

Case Four

5-year-old with multiple urinary tract infections

Dilated renal pelvis and calyces in upper and lower kidney. Dilated proximal ureter.

Case Four

Dilated and tortuous ureter

Case Four

Duplicated collecting system with dilatation of collecting systems of both moieties with

dilated and tortuous ureter.

Case Four

Right ureterocele.

Case Four

Images of the bladder from VCUG show an ovoid filling defect at the right bladder base.

Case Four

ECTOPIC URETEROCELE

Case Four

GRADE 5 VESICOURETERAL REFLUX INTO LOWER MOEITY

(a) Radiograph obtained at excretory urography in a 1-month-old female patient in the supine

position

Callahan M J Radiology 2001;219:226-228

Case Four

Case Five

2-year-old with urinary tract infections

Case Five

Case Six

NEUROBLASTOMA

Case Six

Case Seven

6-month-old with palpable abdominal mass

Case Seven

CYSTIC WILMS

Case Seven

CYSTIC WILMS TUMOR

Case Eight

CLEAR CELL CARCINOMA

2-year-old with palpable abdominal mass on the left

Case Eight

2-year-old with palpable abdominal mass on the left

CLEAR CELL CARCINOMA

Case Nine

6-year-old girl with hematuria

MEDULLARY NEPHROCALICINOSIS

Case Nine

MEDULLARY NEPHROCALICINOSIS NORMAL

Case Nine

STAGHORN CALCULUS NORMAL

Case Nine

STAGHORN CALCULUS

Case Nine

STAGHORN CALCULUS

Case Ten

STAGHORN CALCULUS

Case Ten

2-month-old boy with flank mass

URETEROPELVIC JUNCTION OBSTRUCTION

Case Ten

2-month-old boy with flank mass

URETEROPELVIC JUNCTION OBSTRUCTION

Case Eleven

6-month-old boy with oligouria

Case Eleven

POSTERIOR URETHRAL VALVES

Thank You!¡Gracias!

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