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September 2003 (Vol. 41, Issue 5)
Renal imaging
Guest Editor: Philip J. Kenney, MD

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CONTENTS
pages v-vii
PDF (26 KB)
FORTHCOMING ISSUES
page viii
PDF (18 KB)
Preface
Advances in renal imaging
by Kenney PJ
pages xi-xii
Full Text | PDF (55 KB)
Technical considerations in renal CT
by Lockhart ME, Smith J K
pages 863-875
MR techniques for renal imaging
by Zhang J, Pedrosa I, Rofsky NM
pages 877-907
Evaluation of renal causes of hypertension
by Hartman RP, Kawashima A, King BF
pages 909-929
Evaluation of the hypertensive infant: a rational approach to diagnosis
by Roth CG, Spottswood SE, Chan JCM, Roth KS
pages 931-944
CT urography and MR urography
by Kawashima A, Glockner JF, King BF
pages 945-961
Renal imaging with ultrasound contrast: current status
by Robbin ML, Lockhart ME, Barr RG
pages 963-978
CT evaluation of urinary lithiasis
by Kenney PJ
pages 979-999
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Radiologic Clinics of North America
MR imaging of renal function
by Huang AJ, Lee VS, Rusinek H
pages 1001-1017
Imaging of renal trauma
by Smith J K, Kenney PJ
pages 1019-1035
Imaging of hereditary renal cancer
by Choyke PL
pages 1037-1051
Surgical management of renal tumors
by El-Galley R
pages 1053-1065
Percutaneous image-guided radiofrequency ablation of renal malignancies
by Zagoria RJ
pages 1067-1075
Index
pages 1077-1082
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CONTENTS
Preface xi
Philip J. Kenney
Technical Considerations in Renal CT 863
Mark E. Lockhart and J. Kevin Smith
CT is a robust, rapid means of evaluation for a wide spectrum of urologic disorders. The
evaluation of renal trauma, urologic malignancy, urolithiasis, and vascular anatomy is
well suited to CT techniques. Subtle adjustments, however, in the technical parameters
and timing of the study can optimize the evaluation based on the clinical setting. Because
CT is more widely used, often repeatedly on an individual patient, radiation exposure
must be minimized while still obtaining diagnostic image quality. This article reviews
and discusses technical considerations in the performance of CT for various urologic
clinical indications.
MR Techniques for Renal Imaging 877
Jingbo Zhang, Ivan Pedrosa, and Neil M. Rofsky
Cross-sectional imaging plays a critical role in detection and work-up of renal patholo-
gies. MR imaging provides exquisite, versatile, and unique soft tissue contrast, and allows
for an effective evaluation of a wide range of renal disorders. MR imaging is especially
attractive in assessing renal-related disorders in children, in women of childbearing age,
and in patients with renal insufficiency or renal allografts. This article reviews the cur-
rently available MR imaging strategies for the evaluation of renal-related disorders, and
provides specific recommendations to generate images with consistent diagnostic efficacy.
Evaluation of Renal Causes of Hypertension 909
Robert P. Hartman, Akira Kawashima, and Bernard F. King, Jr
Hypertension currently affects approximately 60 million Americans and can lead to sig-
nificant morbidity and mortality including heart disease and renal failure. Although
most people suffer from essential hypertension, a substantial subset (5% to 10%) has a
secondary cause. Of this group of secondary causes, renal parenchymal disease and ren-
ovascular disease are the most prevalent. This article concentrates on the renal-mediated
secondary causes of hypertension.
ADVANCES IN RENAL IMAGING
VOLUME 41 NUMBER 5 SEPTEMBER 2003 v
Evaluation of the Hypertensive Infant: A Rational Approach to Diagnosis 931
Christopher G. Roth, Stephanie E. Spottswood, James C.M. Chan, and Karl S. Roth
This article reviews and evaluates the pertinent literature and uses this analysis to pro-
vide the basis for a rational diagnostic approach to infantile hypertension. Numerous eti-
ologies of hypertension are discussed and normative blood pressure data for neonates
and infants are provided. Techniques for accurate blood pressure measurement in the
intensive care setting and for routine outpatient settings are discussed.
CT Urography and MR Urography 945
Akira Kawashima, James F. Glockner, and Bernard F. King, Jr
Although there continues to be a lack of rigorous large-scale research on the cost-
effectiveness of various urographic imaging strategies in the evaluation of patients with
hematuria and other urologic indications, sufficient information exists to define a rea-
sonable approach to patients with hematuria. This article describes the evaluation of hema-
turia and reviews developing concepts and evolving techniques of CT and MR urography.
Renal Imaging with Ultrasound Contrast: Current Status 963
Michelle L. Robbin, Mark E. Lockhart, and Richard G. Barr
The application of ultrasound contrast agents to the kidney is still in its infancy; however,
there are several areas of great promise. Ultrasound contrast agents may replace CT in
complex renal cyst evaluation and follow-up. Ultrasound contrast agents are likely to be
clinically useful in the evaluation of the indeterminate small renal mass on CT or MR
imaging. Another probable useful application is in renal artery stenosis. It also will likely
become the first line of evaluation in pyelonephritis, and be useful in immediate assess-
ment of residual tumor after radiofrequency ablation. Substantial additional work needs
to be performed in large groups of patients to prove this currently optimistic outlook.
CT Evaluation of Urinary Lithiasis 979
Philip J. Kenney
Unenhanced CT has been demonstrated to be the most accurate and efficient diagnostic
imaging means to evaluate urinary lithiasis, with capability of directing management,
and is now the standard of practice. It is the duty of the radiologist to be aware of proper
technique and the details of interpretation. The radiologist also has a duty to be aware of
the limitations of unenhanced CT for detection and evaluation of various nonstone dis-
orders, particularly with poor patient selection, and to extend the examination if appro-
priate. Controversies and future developments include cost containment with care for
the selection of patients. Further attempts to reduce radiation exposure should be made.
A consensus should be developed regarding use of CT in pregnant patients. Further
improvements in the digital scout view would be useful for following patients.
MR Imaging of Renal Function 1001
Ambrose J. Huang, Vivian S. Lee, and Henry Rusinek
This article explores technical issues surrounding functional renal MR imaging. The
determination of two important renal functional parameters, renal blood flow and
glomerular filtration rate, is discussed. Finally, specific applications of functional renal
MR imaging in the arenas of renovascular disease, hydronephrosis, and renal transplan-
tation are explored.
vi CONTENTS
Imaging of Renal Trauma 1019
J. Kevin Smith and Philip J. Kenney
Trauma is a major cause of death and disability and renal injuries occur in up to 10% of
patients with significant blunt abdominal trauma. Patients with penetrating trauma and
hematuria, blunt trauma with shock and hematuria, or gross hematuria warrant imaging
of the urinary tract specifically, and CT is the preferred modality. If there is significant per-
inephric fluid, especially medially, or deep laceration, delayed images should be obtained
to evaluate for urinary extravasation. Active hemorrhage should be recognized because it
often indicates a need for urgent surgery or embolization to prevent exsanguination.
Imaging of Hereditary Renal Cancer 1037
Peter L. Choyke
The major hereditary renal cancer syndromes are von Hippel-Lindau disease, hereditary
papillary renal cancer, hereditary leiomyoma renal cell carcinoma, Birt-Hogg-Dub syn-
drome, and tuberous sclerosis. Patients with these syndromes require careful screening with
imaging. In addition to hepheron sparing surgery, hereditary renal tumors can be treated
with minimally invasive techniques, such as radiofrequency ablation and cryotherapy.
Surgical Management of Renal Tumors 1053
Rizk El-Galley
Renal cell carcinoma is a relatively rare tumor, accounting for approximately 3% of
malignancies in adults, but is the most common tumor of the kidney and the third most
common tumor seen by urologists. Renal cell carcinoma is refractory to most traditional
oncologic treatments, including chemotherapy, radiation therapy, and hormonal therapy.
Because of recent advances in sophisticated radiologic studies, the surgeon can now
make an accurate preoperative assessment of the nature and extent of kidney tumors.
When evaluating renal tumors, the urologist looks for certain information to help in con-
structing a management plan. This article explores some of the points that contribute in
the surgical decision-making.
Percutaneous Image-Guided Radiofrequency Ablation of Renal Malignancies 1067
Ronald J. Zagoria
Agrowing body of experience supports the use of image-guided radiofrequency ablation
(RFA) for the treatment of primary renal cell carcinoma (RCC). Image-guided RFA also
shows promise for the successful care of other patients with RCC. In particular, RFAhas
been used successfully for the treatment of intractable hematuria resulting from an RCC;
local recurrences of RCC, both for attempted cure and for palliation of symptoms; and
for the treatment of isolated metastases from RCC. It seems likely that some form of
image-guided percutaneous tumor therapy, such as RFA, will become an alternative
treatment modality in some patients with potentially curable RCC.
Index 1077
CONTENTS vii
FORTHCOMING ISSUES
November 2003
Imaging the Acute Abdomen
Emil J. Balthazar, MD, Guest Editor
January 2004
Arthritis Imaging
Barbara N. Weissman, MD, Guest Editor
March 2004
Emergency Ultrasound
Vikran Dogra, MD, Guest Editor
RECENT ISSUES
July 2003
Womens Imaging: Obstetrics and Gynecology
Deborah Levine, MD, Guest Editor
May 2003
Multislice Helical CT of the Thorax
Phillip M. Boiselle, MD, Guest Editor
March 2003
Advances in Intestinal Imaging
Dean D.T. Maglinte, MD, and
Stephen E. Rubesin, MD, Guest Editors
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Preface
Advances in renal imaging
Upon being invited to edit an issue of the Radio-
logic Clinics of North America on renal imaging, it
was my intention to produce a work that not only
presented the current state-of-the-art but also gave a
glimpse of the future. With contributions from excel-
lent clinician/scientist radiologists, I believe those
goals have been met.
It is striking how much of this issue is devoted to
CT and MR imaging in various forms, with some
ultrasound. Technical advances, particularly multi-
detector row CT, have had a major impact on the eval-
uation of renal disorders. Today, CT and MR imaging
have, to a great degree, replaced standard intra-
venous urography. Several of the sections in this issue
are technically oriented, especially those from Drs.
Lockhart and Smith, Drs. Zhang, Pedrosa, and Rofsky,
and Drs. Huang and Lee, as well as Drs. Kawashima,
Glockner, and King and Drs. Hartman, Kawashima,
and King. Technical developments in CT and MR
imaging now allow for excellent diagnostic capabili-
ties for renal disorders, but detailed specifics of the
technique related to the disorder being sought must be
understood to attain high accuracy.
Two sections, those on renal trauma by Dr. Smith
and urinary lithiasis by Dr. Kenney, could be consid-
ered state-of-the-art presentations in which CT has
clearly demonstrated its primacy, now considered the
one and only in these circumstances. Although
some controversies remain in these areas, and under-
standing of correct technique remains important,
there is little debate about which study to perform. In
some other areas, the authors properly include more
discussion on the advantages and disadvantages of
different methods, commonly CT versus MR imaging,
as well as important discussion as to who should be
evaluated. These relate particularly to evaluation of
hypertension in the adult by Drs. Hartman, Kawa-
shima, and King and in the pediatric population by
Drs. Roth, Spottswood, Chan, and Roth, and the
evaluation of hematuria included in the presentation
of CT urography and MR urography by Drs. Kawa-
shima, Glockner, and King.
While in truth all of the contributors offer some
glimpse of the future, many of the sections concen-
trate on the techniques whereby state-of-the-art cross-
sectional imaging methods can replace and surpass
the radiographic technology (intravenous urography
and catheter angiography) of the past. However, the
discussions of MR imaging of renal function by
Drs. Huang and Lee, and renal imaging with ultra-
sound contrast present techniques whereby previously
available technology can be used to derive new infor-
mation. Combination of anatomic and functional
information can lead to new uses of imaging.
Finally, although many of the sections deal with di-
agnosis of the renal mass (and properly so, considering
this is a common problem), several sections expand the
perspective. It is not enough for the radiologist today to
understand technique and interpretation for accurate
diagnosis; one must also have some understanding of
0033-8389/03/$ see front matter D 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0033-8389(03)00122-2
Philip J. Kenney, MD
Guest Editor
Radiol Clin N Am 41 (2003) xi xii
the basic principles of the disease, including genetics,
as well as the treatment options. In contributions from
Drs. Choyke, Zagoria, and El-Galley, a deeper under-
standing is provided of the various diseases called
renal carcinoma, and of the wide variety of treatment
options now available, whether provided directly by a
radiologist or by urologic surgeons.
Department of Diagnostic Radiology
University of Alabama at Birmingham
JT N370
619 19th Street South
Birmingham, AL 35249-6830, USA
E-mail address: pkenney@uabmc.edu
P.J. Kenney / Radiol Clin N Am 41 (2003) xixii xii
Technical considerations in renal CT
Mark E. Lockhart, MD, MPH
*
, J. Kevin Smith, PhD, MD
Department of Radiology, University of Alabama at Birmingham, 619 19th Street, South JTN363, Birmingham,
AL 352496830, USA
The use of radiologic imaging, specifically CT,
continues to grow in diagnostic importance. The
impact of CT on medicine and urologic evaluation
has transformed it from an exotic tool into a diag-
nostic cornerstone. Few patients with urinary symp-
toms or signs escape diagnostic imaging, and most
undergo multiple examinations. For decades, intra-
venous (IV) pyelogram was the primary means of
noninvasive evaluation of the upper urologic system.
In the last 20 years, however, the application of CT
in urology has exploded. In many institutions, CT
has largely replaced the use of IV pyelogram. This
article reviews and discusses technical considera-
tions in the performance of CT for various urologic
clinical indications.
CT has undergone many changes and improve-
ments since its development. The earliest scanners
used axial imaging and a single beam of radiation and
required minutes to reconstruct the most basic
images. As the scanners were improved, the speed
of acquisition and image quality grew proportionally.
The medical benefits and number of uses became
widely accepted, and by the late 1990s CT was firmly
entrenched as a primary diagnostic tool. One major
improvement was the use of slip-ring technology to
create helical data acquisition as the patient was
slowly moved through the rotating radiation beam.
Subsecond scanners were developed and when com-
bined with slip ring helical scanning was fast enough
to follow contrast boluses through the vessels for CT
angiography (CTA). Today, thinner slices require
additional radiation and yield more images than
ever. Larger heat capacity tubes, increased computer
processor capability, and faster and larger data storage
methods have also been developed. Reconstruction
times have approached real-time review of the data.
More recently developed scanners use multiple rows
of detectors to capture multiple image slices from
the single beam of radiation that passes through a
patient. The entire abdomen can be studied in less than
15 seconds, within a single breathhold. With increased
image speed and quality, CT has made major inroads
into vascular imaging. New developments include
plate detector technology, which allows volumetric
reconstruction in any plane, a long-time advantage of
MR imaging over CT.
Basic concepts
Pitch
Pitch is a term that is used to describe the relative
movement of the patient as the x-ray source and
detector circle to acquire data. For axial CT, the pitch
is zero because the table is not moving as the data
are acquired. Single-detector helical CT pitch is deter-
mined by table speed in centimeters per second
divided by slice thickness.
The calculation of pitch in multidetector is more
complicated and different manufacturers use two
separate methods of description. On General Electric
scanners (GE Medical Systems, Milwaukee, WI), for
example, the pitch is expressed as the table speed
divided by the nominal slice thickness. On current
four-channel CTs, however, the total x-ray beam
width is four times the nominal slice width. For
example, a 1.25-mm slice thickness study with a
table speed of 7.5 mm per gantry rotation yields a
pitch of 6, 7.5 mm per 1.25 mm. A more widely
doi:10.1016/S0033-8389(03)00065-4
* Corresponding author.
E-mail address: mlockhar@uabmc.edu (M.E. Lockhart).
Radiol Clin N Am 41 (2003) 863875
accepted definition (eg, used on Siemens [Erlangen,
Germany] CT scanners) of pitch is the table speed per
rotation divided by the x-ray beam width. For a four-
channel system with 1.25-mm slice thickness this
technique has a beam width of 4 1.25 mm = 5
mm, and this definition yields a pitch of 1.5, or 7.5 mm
per 5 mm. For subsecond scanners the length of
coverage increases relative to a 1-second scanner
proportionally for the same technique. A 0.5-second
scanner can cover twice the distance in the same time
as a 1-second CT using similar technique.
An equivalent to 1 pitch for a single-detector CT
should be used in the evaluation or characterization of
renal lesions to decrease volume averaging from slice
profile broadening. A pitch 1.5 to 2 is often used to
cover rapidly an adequate volume for CT angiogra-
phy or trauma evaluation. This allows increased
coverage speed to track the contrast bolus without
much detriment to effective slice thickness [1].
Detectors
There are now a large variety of detector configu-
rations in use. Currently, new scanners generally use
a rotating radiation source with an attached arc of
rotating detectors that are composed of multiple
contiguous detector rows. There is wide variation in
the number of detector arrays produced by various
manufacturers. Some scanners have equally sized
detectors and others have smaller detectors in the
central beam region with larger detectors at the
periphery. Each of the systems allows the combina-
tion of several detectors to allow images of different
slice thickness during image acquisition. In addition,
there is variation in the number of helices generated
based on the number of rows of detectors and
separate data channels. The number of helices has
increased from 1 to 2 (dual-slice) to 4 and now 16 in
the last decade. There will soon be availability of
32-row CT scanners with developments of still more
rows of detectors and channels to allow even faster
imaging in the near future.
Reconstruction
In single-detector helical CT or multidetector-row
CT (MDCT), the raw data are acquired at a different
level of the patient from each vantage point depend-
ing on where the x-ray source is located in its circle.
To calculate a slice of image data that seems axial
rather than a helix, the data from different points in
the helix are interpolated to the displayed level. This
interpolation leads to slice profile broadening and
may also lead to artifacts. With multislice scanners
the part of the x-ray beam that strikes the outside
detectors passes through the patient at more of an
angle than the part of the x-ray beam that strikes the
central detectors, the so-called cone beam effect.
This angle leads to errors in image reconstruction and
artifacts if not taken into account, so multislice
scanners must either scan at certain pitches that
cancel out these effects or use special cone beam
image reconstruction algorithms.
The raw helical CT data are generally recon-
structed into axial images and these images may then
be used to generate images in any plane, but the off-
axis images are often suboptimal if the original slices
are too thick. With thinner slices and high milli-
amperes and kilovolt (peak), high-quality reconstruc-
tions are possible. New workstations and software
have greatly reduced reconstruction time, especially
in vascular imaging.
The volumetric acquisition is beneficial in opti-
mizing of even axially oriented images with regard to
a specific lesion. Thinner slice reconstructions may
be adjusted to center the slice volume on the lesion to
reduce volume averaging with the adjacent paren-
chyma and provide more accurate assessment of
lesion enhancement. This may be performed retro-
spectively on the data set without the resultant
increased radiation of rescanning the patient.
Contrast selection and types
Routine protocols: concentration and total dosage
In routine applications, approximately 125 to
150 mL iodinated contrast is given by reliable IV
access. At a standard 2 to 3 mL/second injection rate,
the contrast bolus lasts 60 to 75 seconds. Both high-
and low-osmolar IV contrast result in satisfactory
image quality. Initially, low-osmolar contrast was
very expensive, and selective usage of low-osmolar
contrast was the norm because of the large cost
difference between high- and low-osmolar contrast
agents. Patients with increased risk of allergy, renal
insufficiency, or other indications were given low
osmolar, whereas the standard was to give high-
osmolar contrast. As the price difference has dimin-
ished, many institutions have selected low-osmolar
agents for all of their routine contrasted CTs.
For patients with decreased renal function, lower
contrast volumes are often given to reduce the risk of
contrast-induced nephrotoxicity. There is no degra-
dation of enhancement when the contrast dosage is
1.5 mL/kg or greater [2], and with faster multislice
M.E. Lockhart, J.K. Smith / Radiol Clin N Am 41 (2003) 863875 864
scanners it may be possible further to reduce the dose
for such studies as CTA.
Injection rates
The current standard of care for abdominal CT
uses controlled IV bolus of contrast by a power
injector. For routine imaging of nonspecific renal
complaints or characterization of a renal mass, the
standard infusion rate is 2 to 3 mL/second. This can
be accomplished through any number of IV access
sites. Injection through a small (3 to 4F catheter
diameter) peripherally inserted central catheter is
not practical because of the small bore and length
of the catheter and the viscosity of the contrast [3].
The injection rate may also be limited for some other
central venous catheters. Concern for power injection
of contrast directly into the cardiac chambers is
present because of the possibility of inducing a
cardiac arrhythmia, but studies have suggested that
central catheter injection of contrast is safe with
adequate injection rate guidelines [4,5].
If CTA is needed, higher injection rates are
necessary to opacify the arteries densely. Typically,
a rate of 3 to 5 mL/second is selected for CTA imaging
of the renal vessels (Fig. 1). This requires a reliable
20-gauge or larger IV line in a good antecubital vein.
An 18-gauge IV line can allow up to 7 mL/second, but
the authors do not use this rapid rate on their CTA
studies. Before power injection, their technologists
test the IV line with a rapid hand injection of saline to
evaluate for any extravasation. Pressure limits are
used for the power injection to limit the volume
injected if an extravasation of contrast outside the
vein occurs.
Oral contrast versus water
In renal imaging, the choice of oral contrast agent
is less critical than in gastrointestinal imaging. There
are cases, however, where the choice of oral contrast
can impact a renal CT. In evaluation of renal calculi,
dense oral contrast in the small bowel can make
detection of a ureteral calculus more difficult. CTA
is another clinical situation where positive oral con-
trast can be counterproductive; no oral contrast is
given, or water may be selected. The density of oral
contrast may lie adjacent to vessels and significantly
increases the difficulty of three-dimensional recon-
struction (Fig. 2). For renal donor evaluation and
renal mass evaluation of vascular supply for surgical
planning, water is preferable to positive oral contrast
for bowel distention.
High-concentration contrast: new uses
Recent research has used high-concentration con-
trast agent for CT imaging. The most obvious appli-
cation is for CTA. Dense agents can be used to allow
improved opacification of small vessels to allow
reconstruction of the vascular anatomy. In the urologic
system, this may allow demonstration of vascular
abnormalities, such as arteriovenous malformations;
small aneurysms; tiny accessory arteries; and subtle
vascular abnormalities, such as mild fibromuscular
dysplasia. Other possible applications include demon-
Fig. 1. CT and CT angiography at the level of the kidneys demonstrate differences in enhancement using routine and high-rate
injection rates. (A) Standard injection rate of contrast 2 to 3 mL/second with good contrast enhancement of the vessels and renal
parenchyma. (B) High-rate injection of contrast 4 to 5 mL/second with arterial timing using same CT scanner in the same patient
at a different date demonstrates higher density within the aorta and renal vessels. Denser cortical enhancement also is noted.
stration of artery course and appearance to help
characterize renal masses.
CTA: technical differences
CT angiography optimizes CT technique for the
opacification and display of the arterial system. Tech-
nical differences include timing of the contrast bolus,
slice thickness, dose, pitch, and reconstructions.
Two methods are generally used for selecting the
optimal timing for CTA imaging: test injection or
bolus tracking. For test injection, a small-volume
bolus is injected at a similar rate to the desired
CTA injection rate. A single level low-dose CT scan
is repeatedly imaged through the aorta at the area of
interest. This technique generally uses less than
100 kV and less than 100 mA performed every 2 to
3 seconds [6]. Once peak enhancement is noted, the
calculated interval is selected as the delay for imag-
ing. Alternatively, bolus tracking does not use a test
injection; rather, the diagnostic bolus is tracked using
similar low-dose repetitive imaging. When contrast
reaches the left ventricle or proximal aorta depending
Fig. 2. Reconstruction images in the coronal plane of CT
angiography in a patient who received iodinated oral contrast
before the study. The overlying dense contrast within the
bowel increases the difficulty to visualize the abdominal
vessels separately.
Fig. 3. Reconstruction techniques at the level of the kidney with renal artery aneurysm for CT angiography using (A) maximum
intensity projection, (B) shaded surface reconstruction, and (C) volume rendering.
on area of interest, the scan is initiated either auto-
matically or manually. The tracking level is generally
chosen upstream from the area of interest because
there is a slight delay before images are obtained as
the scanner moves to the starting position and
changes anode current. Helical images then chase
the contrast bolus as it flows farther from the heart.
At each level the arteries are densely opacified during
the time of imaging. Thin slices (usually 1 to 3 mm
thick) are obtained with sufficient radiographic tech-
nique such that mottle is not limiting. In the standard
helical CT and some early MDCT, a higher pitch may
be necessary to keep up with the contrast and to scan
the area of interest within the heat capacity of the
x-ray tube and the breathhold capacity of the patient.
With newer scanners, there is the possibility of out-
running a tight contrast bolus if the scan is too fast or
started too early after the bolus arrival.
Oral contrast is not given in CTA so that the only
dense contrast is within the arteries. This is essential
for ease of three-dimensional reconstruction, which
uses threshold selection, maximum intensity projec-
tion, or volume rendering for reconstructions. If
necessary to answer additional clinical questions,
water can be given as an oral agent. Although
multiple phases of imaging can be performed using
high-capacity heat tubes, the thin slices and high
radiographic technique may result in substantial dose
to the patient.
A limitation of traditional CTA is the suboptimal
timing of solid organ enhancement. The technique is
less sensitive for renal masses compared with nephro-
graphic phase imaging. Central masses especially
may be missed because the hypoenhancing mass
may be indistinguishable from the relatively hypo-
enhancing renal medulla.
Reconstructions are often performed to present
images that resemble angiography. Reconstruction
techniques that are commonly used are maximum
intensity projection, shaded surface reconstruction,
and volume rendering (Fig. 3). At the authors institu-
tion, a trained technologist rapidly reconstructs the
images. New workstations have streamlined the pro-
cess, and are much faster and more user friendly than
even systems from a few years ago. Life-like three-
dimensional images may be constructed from various
perspectives including a surgical viewpoint for the
specific procedure in question. Images showing rota-
tion of the three-dimensional volume or progressive
removal of overlying structures may be helpful. The
reconstructions can be very useful in localizing a renal
tumor for segmental or laparoscopic resection. The
relationships of the mass to the adjacent structures,
such as chest wall, can be demonstrated exquisitely. In
healthy patients, CTA can characterize the arterial and
venous supply to the kidneys to help select the easiest
and safest kidney for renal donation.
Timing and technique issues
Nonenhanced CT for urolithiasis
Noncontrast CT has become the primary radio-
logic study for the evaluation of renal stones. Some
specific technical issues remain unresolved. In the
evaluation of known renal calculi with renal colic or
hematuria, CT without IV or oral contrast is usually
adequate and quick. In a significant proportion of
patients with less specific presentation, no stone is
found. Many of these patients may eventually receive
a CT with oral and IV contrast. If no oral contrast was
given for the initial renal stone CT, the patient must
be moved from the scanner and given time to drink
the oral contrast to optimize the contrasted study. The
administration of oral contrast before renal stone
protocol may allow the IV contrasted study imme-
diately to follow the stone study, reducing patient wait
and improving study time efficiency. Oral contrast,
however, has the potential to mask a ureteral calculus
that abuts bowel.
Occasionally a calcification is noted in the pelvis,
but the ureters cannot be followed at the level of the
calcification. In these cases, limited images of the
pelvis may be performed at 3 to 5 minutes after low-
dose IV contrast to identify the ureters and determine
whether the calcification is vascular or urologic. If the
symptoms are less typical of renal colic, it may be
preferable to include the upper abdomen on con-
trasted imaging to help exclude other possible causes
of abdominal symptoms. In one series, 13.1% of
unenhanced CT for evaluation of urinary tract calculi
subsequently received IV contrast [7].
Another question arises in the setting of hematuria
without definite renal colic. In these patients, a non-
contrast renal stone CT may be a reasonable first
study. The absence of renal calculi, however, should
prompt a CTwith IV contrast. In the study by Gottlieb
et al [7], approximately 6% of studies for urinary
calculi demonstrated a nonurologic cause for symp-
toms, such as appendicitis or diverticulitis. The timing
is usually at 70 to 90 seconds after injection to exclude
renal tumor or infection as an etiology. Pelvis images
are performed after a 3-minute delay to allow filling of
the urinary bladder with contrast.
If the collecting systems have fluid-filled struc-
tures, and parapelvic cysts versus hydronephrosis are
a consideration, a postcontrast scanogram scout can
often show whether hydronephrosis is present. Other-
wise, delayed axial images of the kidneys may be
obtained and clearly differentiate parapelvic cysts
from the collecting system (Fig. 4). Delayed images
also may be helpful for patients with an obstructing
stone and moderate or large amounts of peripelvic
fluid to evaluate for calyceal rupture.
Trauma and general evaluation
A common indication for CT, which includes renal
evaluation, is blunt abdominal trauma. Helical CT is
the modality of choice in the evaluation for renal
laceration or contusion. Indications commonly are
gross hematuria or microscopic hematuria with hypo-
tension or additional signs of abdominal hemorrhage.
Faster scan acquisition is beneficial to reduce motion
artifacts in a noncompliant or obtunded patient.
Breathing misregistration also is reduced in rapid
image acquisition. Images with severe motion can
be reconstructed using part of the helix to determine
whether a finding is artifact or a true injury. This is
rarely necessary, however, in the urologic system.
Helical 5-mm images of the abdomen and pelvis
with a 1.5 pitch are performed at the authors insti-
tution for blunt abdominal trauma. IV contrast is
routinely administered using 125- to 150-mL low-
osmolar contrast at 2 to 4 mL/second rate. IV access
is preferred in the antecubital fossa, but hand or lower
extremity venous accesses may be used if necessary.
After injection, there is a 60- to 80-second delay
before image acquisition. The length of the delay
mostly depends on the scanner; multidetector-row
scanners need the slightly longer delay to prevent
premature imaging of the abdominal organs. In
MDCT, the scans are performed more quickly. The
timing used for single-detector CT may yield images
that are too early for optimal evaluation.
Active extravasation of arterial or venous contrast
may be detected during the nephrographic phase as a
collection or linear track of dense contrast emanating
from the renal parenchyma or renal hilum [8,9].
Delayed images may be useful in the setting of
trauma if there is renal laceration or perinephric fluid
to suggest hematoma or urinoma. The delay is
generally performed approximately 10 minutes after
contrast injection. Contiguous 5-mm thick images are
usually adequate in this portion of the examination.
Delayed or excretory images may detect renal hemor-
rhage or urinoma that is not visible on routine images
(Fig. 5) [10].
Renal mass imaging
The most common nonemergent indication for
renal CT at the authors institution involves evalua-
tion or staging of a renal mass. The mass may be
symptomatic or one of the increasing number of
incidental findings detected as more CTs are being
performed. Multiphase imaging in a patient with renal
mass can serve one of two broad purposes: charac-
Fig. 4. Corticomedullary phase CT of kidney (A) shows central low-attenuation structures. Excretory phase images (B) show that
the structures do not fill with excreted contrast and represent parapelvic cysts.
terization of the renal lesion, or staging and detection
of metastatic disease.
With regard to renal mass characterization, the
typical protocol includes unenhanced and contrasted
portal and nephrographic phase images (Fig. 6).
Unenhanced images are performed to detect calcifi-
cations within the lesion. Also, they provide a base-
line density to allow evaluation of enhancement. At
the authors institution, 5-mm slice thickness is the
standard for unenhanced images. Subsequent images
after IV contrast are performed in a similar manner
after 70- to 90-second delay after injection.
If staging of a known mass is desired, three-phase
CT is performed through the liver and kidneys. Occa-
sionally, delayed images of the liver may be performed
to help characterize an indeterminate liver lesion. The
typical arterial phase images begin 25 seconds after
start of IV contrast injection. The timing can also be
Fig. 5. Contrasted CT through the level of the kidneys in a trauma patient. (A) Portal phase shows perinephric fluid, possibly
hemorrhage or urine. (B) Delayed images show dense contrast leaking from the collecting system into the perinephric space
confirming urinoma.
Fig. 6. Multiphase CT through the level of the kidneys performed for renal mass detection. (A) Precontrast images through the
level of the right kidney show mildly hypodense region in the right kidney. (B) Postcontrast images through the same level show
enhancement of a focal lesion in the region of precontrast hypodensity. Subsequent pathology confirmed renal cell carcinoma.
adjusted using a bolus tracking method or small timing
bolus. The portal phase starts 70 to 90 seconds after
injection for hepatic imaging.
The nephrographic phase of the kidneys occurs
80 to 180 seconds after injection [11]. Some authors
suggest timing of renal images at least 100 seconds to
ensure homogenous enhancement during nephro-
graphic phase [12,13]. Others have suggested a
120- to 150-second delay [14]. The detection of renal
masses is reportedly improved in the nephrographic
phase relative to the earlier corticomedullary phase
[12,15]. A small lesion can be detected that may
blend with the cortex on corticomedullary images
(Fig. 7). On nephrographic phase images, homo-
genous enhancement of the renal veins is also useful
to evaluate for venous invasion. There is only occa-
sionally a benefit to further delayed images of the
kidneys or liver in these patients.
Delayed images may also be performed after con-
trast is excreted into the collecting systems. The
excretory phase begins 3 to 5 minutes after contrast
injection. These images may be useful in the evalua-
tion of central renal masses, whether renal cell carci-
noma or transitional cell carcinoma (TCC). Filling of
the collecting systems allows detection of distortion of
the calyces or renal pelvis. Extension of tumor along
the urothelium can suggest TCC as the etiology of a
mass because renal cell carcinoma does not usually
extend along the collecting system or ureter. Three-
dimensional or multiplane reconstructions can be
helpful in these examinations. Axial images as thin
as 1-mm images may be performed to allow coronal
reconstruction or maximum intensity projection
images of the collecting systems and ureters. The
optimal delay of imaging after start of contrast infusion
is 5 to 10 minutes. A postinjection 250-mL drip
infusion of saline before delays can be used to distend
the ureters [16]. External compression over the pelvis
may help distend the ureters and collecting systems
[17,18].
If a dense renal mass is detected on routine CT,
there may be no precontrast images to calculate
enhancement. In these cases, delayed images can
show de-enhancement of a renal tumor (Fig. 8).
Vascular renal masses, such as renal cell carcinoma,
decrease in density on delayed images. At least one
article has shown benefit in delayed images, from as
soon as 30 minutes to 4 hours, to evaluate whether
the lesion has vascularity. The authors suggest that a
decrease of 15 HU or more is consistent with tumor.
Alternatively, a hyperdense renal cyst shows no
change in density between corticomedullary and
delayed-phase images [19].
CTangiography of the kidneys may be specifically
requested to evaluate the renal vasculature or the
relationship of vasculature to tumors. This can be
extremely important for planning of laparoscopic or
limited-incision nephrectomy or partial nephrectomy.
In the authors experience, CTA has been very useful
in preoperative evaluation of tumors within horseshoe
kidneys. The vessels are often distorted and there is
often variable vascular supply to the central portions of
Fig. 7. Contrasted CT during corticomedullary phase (A) shows no focal abnormality. Repeat CT through the same level (B) with
nephrographic timing demonstrates small enhancing mass, which was confirmed as renal cell carcinoma.
the fused kidney. Helical 1.2- to 2.5-mm slices are
obtained using arterial phase timing. Timing is per-
formed using a bolus tracking system or timing bolus
to ensure optimal opacification of the arteries. This is
especially important in patients with abnormal cardiac
output [20] or young hyperdynamic patients.
Renal donor evaluation
Up to five series have been used in the evaluation
of patients for renal donation [21]. In the evaluation
of potential renal donors at the authors institution,
however, three series are typically obtained to reduce
radiation dosage to the healthy donor. Noncontrast
images are initially obtained to evaluate for nephro-
lithiasis and as baseline for measurement of enhance-
ment in case a renal lesion is detected. The images
also permit characterization of any adrenal nodules,
if present.
Intravenous contrast is given at a rate of 3 to
5 mL/second (preferably 5 mL/second), and arterial
phase images are obtained to evaluate renal vascula-
ture and allow three-dimensional reconstructions. The
authors use a MDCT with 1.25-mm images obtained
after a delay determined by bolus tracking. Late portal
or nephrographic-phase images allow detection of
renal masses, parenchymal abnormalities, cysts,
and extrarenal abnormalities. For these images, helical
5-mm images are obtained after a 90- to 180-second
delay from the time of injection.
At the authors institution they perform a postscan
scout image to evaluate for ureteral duplication. Other
authors have suggested that the resolution of the CT
scout is insufficient to exclude medullary sponge
kidney or papillary necrosis, and they recommend
postcontrast conventional radiography [21].
Crossing vessels evaluation
An increasing use of minimally invasive proce-
dures on the urologic system has brought potential
new complications, whether because of limited visua-
lization caused by smaller incisions in open proce-
dures or endoscopic limitations. Endoscopic repair of
ureteropelvic junction obstruction can be performed
using a blind incision through the ureter wall. A
potential complication occurs if the incision encoun-
ters an abnormally positioned renal artery. Abnormal
crossing vessels are documented in up to 50% of the
population [22] and in greater than 50% of patients
with ureteropelvic junction obstruction [23]. The
vessels are usually anterior to the ureter. Ureterotomy
is typically performed in the posterior aspect of the
ureter wall to minimize the risk [24]. Posterior
crossing vessels are common, however, representing
6 of 13 crossing vessels in cases of ureteropelvic
junction obstruction in one series [23], and may result
in postprocedure hemorrhage. CTA is very accurate
in detecting crossing renal arteries and can help
prevent such problems.
Fig. 8. De-enhancement of incidentally discovered renal mass in a patient in whom precontrast images were not obtained.
(A) Contrasted CT at the level of the kidney shows hyperdense lesion measuring 117 HU. (B) Subsequent short-interval delayed
image at the same level measures 91 HU in the same region, confirming vascularity of the lesion.
Radiation dosage issues
Single detector versus MDCT radiation dosage
Although many parameters and terms have
changed since the advent of multislice CT, the cal-
culation of dose is the same for single-slice helical
CT as it is for multislice CT. Initial estimates showed
that MDCT results in higher radiation dosages if
techniques similar to SDCT are chosen. Lower milli-
ampere and kilovolt (peak) settings, however, yield
similar quality images with similar dosimetry. Because
there are multiple rows of detectors, the penumbra of
radiation for one slice is beneficial to the adjacent slice
in the central detectors. Although the radiation dose
experienced by the patient from the radiation beam is
similar to single-detector CT, the MDCT makes more
efficient use of the total radiation produced by the tube
because it gets multiple slices for the same tube current
and time.
Low-dose renal calculus
Radiation exposure has moved to the forefront in
the national media and radiologic community. As
diagnostic imaging, mainly CT, has become more
commonplace, it has become one of the largest man-
made contributors to population radiation exposure.
At the authors institution, over 12 million CT images
have been generated since January 1999. As the
amount of CT imaging increases, there are concerns
of deleterious effects that this radiation could have on
society and individuals regardless of outcome of
persistent debate whether threshold effects exist with
respect to CT levels of radiation dosage. It is essential
to avoid unnecessary exposure and reduce the radia-
tion exposure to the lowest possible levels while still
producing diagnostic image quality.
In pediatric populations, CT is a significant source
of radiation. Pediatric CT protocols for detection of
urinary tract calculi vary by institution. The best ways
to reduce dose include a reduction in milliampere and
increase in pitch [25]. In one study, three techniques
for renal calculi chose 3- to 5-mm collimation, 180 to
280 mA, pitch 1:1 to 2:1, and 120 kVp. These values
yielded estimated ovarian dose of 0.31 to 1.07 rad to
the child. It is noted that by reducing the milliampere
to 100 and using 2:1 pitch the estimated ovarian dose
is 0.15 to 0.26 rad, a significantly reduced dose that
provided diagnostic image quality [26]. Commonly, a
pitch of 1.5 or 2 may be used in pediatric patients
without loss of diagnostic information [25].
Dose reduction is most commonly discussed
in pregnant and pediatric patients, as is justified.
Several other situations, however, should trigger
additional effort to reduce dose. In young patients,
especially young women, who are expected to have
repeated CT studies in the future, extra effort should
be taken to reduce the dose to the minimum possible.
These patients may include complicated pancreatitis
patients, chronic renal stone formers, or young
patients with treated tumors who have good progno-
sis but need repeated follow-up to monitor for recur-
rence of tumor.
Several articles have discussed low-dose tech-
niques for detection of renal calculi with good clinical
results in adults. Hamm et al [27] showed sensitivity
and specificity of 96% and 97%, respectively, using
120 kV, 70 mA, 5-mm collimation, pitch 2, with
5-mm reconstructions. This technique reduced radia-
tion exposure by 50% to 1.50 mSv, which was com-
parable with exposure for excretory urography [27].
This was similar to results noted by Liu et al [28] using
a protocol with 7-mm slices and a slightly higher
technique yielding an exposure of 2.8 mSv. The
authors noted that the technique might be limited in
obese patients [27]. Tack et al [29] have recently sug-
gested 30-mA technique with further focused imaging
can be accurate, but as noted in an accompanying
commentary, a 60-mA technique may eventually be
determined as more appropriate for adequate diagnosis
of urinary or unexpected nonurinary etiologies in adult
patients in the United States [30].
Because dosimetry is similar for single-detector or
multidetector CT, the methods to minimize the pa-
tient radiation dose are similar in both systems. The
deposited radiation correlates directly in a propor-
tional manner to the milliampere used. Double the
milliampere results in double the patient dose, when
all else remains equal. Even small reductions in kilo-
volt (peak) significantly reduce image quality without
significantly reducing patient radiation. Dose reduc-
tion is usually best achieved through reduction of the
milliampere rather than kilovolt (peak). Typically, the
milliampere is approximately 200 to 240 for 5-mm
thick images in a standard CT of an adult patient. In
pregnant patients, the authors often reduce the milli-
ampere to 60 to 100, depending on patient body
habitus. Increasing the pitch can significantly reduce
dose to the patient. The effective slice thickness in
the z-axis may be increased, however, and this
could reduce sensitivity for small lesions, such as
ureteral calculi.
Pregnant patient evaluation
One of the most effective methods of dose reduc-
tion is the appropriate selection of alternate modali-
ties that do not use ionizing radiation. The kidneys
often are well demonstrated by ultrasound, and ultra-
sound should be considered as a primary examination
in the evaluation of renal abnormalities in pregnant
patients. The latest ultrasound machines have many
techniques to aid in organ visualization, such as
harmonic and pulse inversion imaging. Ultrasound
usually does not image the ureters well and may miss
smaller stones or tumors in the kidneys.
MR imaging is an excellent alternative modality
for renal evaluation despite its expense and sensitivity
to motion artifact. In patients who are able to have the
study, the kidneys can be quite well evaluated.
Additionally, there is less risk of nephrotoxicity,
which is a concern when performing CT of patients
with renal insufficiency. MR angiography provides
excellent evaluation of the abdominal and pelvic
arterial systems.
In pregnancy, as in all patients, the principle of
as low as reasonably achievable is followed. Still,
there are certain times in the gestation of a pregnancy
that are more susceptible to the effects of radiation.
The period of organ morphologic development in the
first trimester is of special concern. The third trimes-
ter is the period of least sensitivity to the effects of
radiation, but dose reduction is still crucial in these
patients. In the acute setting, such as after severe
trauma, where the life of the mother is at significant
risk, the radiation dose reduction should be secondary
to diagnostic image quality. In these circumstances
CT may be performed without hesitation because the
death of the mother from a missed injury would
likewise result in death of the pregnancy.
After trauma, the CT most often requested in
pregnant patients is for the evaluation of renal colic.
Often there are hemodynamic changes of pregnancy,
and many women may have episodes of dehydration,
predisposing to renal calculi. The evaluation of renal
colic in a pregnant patient is a difficult diagnostic
situation. There may be hydronephrosis of pregnancy
complicating the imaging picture. Also, the enlarged
uterus often displaces the ureters. In these patients,
low-dose noncontrast CT is usually performed if a
calculus is not evident on conventional abdominal
radiograph. The dose should be reduced as much as
possible, but care is taken not to perform a non-
diagnostic study, which is a needless radiation expo-
sure. A single test slice may be performed through the
upper abdomen above the uterus to evaluate whether
a reduced technique yields too much noise to detect a
small stone. Low-dose noncontrast CT has all but
replaced limited IV pyelogram in stone evaluation at
the authors institution even in pregnant patients
because of the significantly higher sensitivity and
specificity of CT.
Pediatric CT issues
Dose reduction
Pediatric renal CT is most commonly performed
to evaluate for renal mass, such as Wilms tumor. CT
is an excellent modality to evaluate for adenopathy or
renal vein involvement. Distant metastases are also
detectable by CT. For infants, the radiographic tech-
nique is significantly lower than for adults because of
the lower body mass of the patient. Standard milli-
ampere and kilovolt (peak) values for children vary
by the size of the child. For an infant, 60 to 70 mA
and 120 kVp have been recommended. For a larger
child who weighs 60 to 79 lb, 100 mA and 120 kVp
are adequate. Adult protocols using 220 mA, how-
ever, are not appropriate for pediatric patients [25].
The timing of imaging for standard abdominal eval-
uation is earlier than in adults (50 versus 70 seconds)
because of the faster circulation time. The volume of
IV contrast is 1 mL/lb or 2 mL/kg given at a rate of
1 to 3 mL/second or by hand injection.
Alternative modalities to limit radiation exposure
In children, there are several alternative imaging
methods for evaluation of renal disease. Because of
the small size of the patients, excellent sonographic
penetration is possible. The kidneys are smaller and
closer to the skin than in adults, so higher-frequency
transducers may penetrate to the kidneys well and can
provide excellent spatial resolution and image quality.
MR imaging is an alternative, but it may require
sedation in younger pediatric patients.
New concepts
Volumetric acquisition: plate detectors
Although makers of CT scanners continue to
make incremental improvements in number of rows
of detectors, the next major transition will likely
include image plate detector technology in CT. There
have been early articles using video fluoroscopy or
image intensifiers published on the developing tech-
nology [31,32] and it may greatly improve the spatial
resolution of CT for imaging of very small structures
within the body. Characterization of smaller feeding
vessels will be possible. Less volume averaging or
pixelation of the images should improve image qual-
ity. Because there will be no spacing between detec-
tors, less radiation should remain uncollected in the
image acquisition.
Molecular imaging applications
There are no reimbursed routine indications for
molecular imaging for the initial detection of tumors
in the kidneys. Although many tumors, such as
lymphoma, can be detected and characterized easily
with fluorine-18-fluorodeoxyglucose positron emis-
sion tomography, renal cell carcinoma has not shown
as much promise with this agent. Positron emission
tomography has high positive predictive value in this
setting, however, and may be used for characterization
of lesions detected by other modalities [33]. This
technique may be used for evaluation of residual
tumor after nephrectomy. It also may be used to
evaluate response to therapy for metastatic disease
[33]. Similar benefits may be seen for tumors of the
urinary bladder, but the applications in prostate cancer
evaluation may be limited [33]. It is hoped that
additional agents will move into general practice to
enable physicians to characterize the metastatic poten-
tial of renal lesions. Positron emission tomography CT
imaging is growing in usage and combines high spatial
resolution images of the anatomy by CT with the
functional images of positron emission tomography.
The CT technique used for attenuation correction at
the authors institution generally consists of 130 kVp
and 90 mAwith 0.8-second helix in this situation.
Compression for distention
Another variant of standard CT uses a technique
commonly used in IV urography. In IV urograms, the
initial images of the collecting systems are obtained
with improved distention of the proximal collecting
systems by using compression pads placed over the
pelvic brim. The same concept can be applied to CT
for the imaging of the renal collecting systems in the
evaluation for possible TCC. The technique may also
be helpful in determining whether a renal cell carci-
noma extends to the urothelium for surgical planning.
Compression over the ureters allows increased dis-
tention of the proximal collecting system. Release of
compression may improve filling of the ureters
[18,34] for evaluation of an urothelial mass or clot.
Summary
CT is a robust, rapid means of evaluation for a
wide spectrum of urologic disorders. The evaluation
of renal trauma, urologic malignancy, urolithiasis,
and vascular anatomy is well suited to CT techniques.
Subtle adjustments in the technical parameters and
timing of the study, however, can optimize the
evaluation based on the clinical setting. As CT is
more widely used, often repeatedly on an individual
patient, radiation exposure must be minimized while
still obtaining diagnostic image quality.
Acknowledgments
The authors thank Trish Dobbs for her assistance
with manuscript preparation, and Anthony Zagar for
photographic assistance.
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MR techniques for renal imaging
Jingbo Zhang, MD, Ivan Pedrosa, MD, Neil M. Rofsky, MD
*
Department of Radiology, Beth Israel Deaconess Medical Center, Shapiro 4 Clinical Center, 330 Brookline Avenue, Boston,
MA 02215, USA
Cross-sectional imaging plays a critical role in
detection and work-up of renal pathologies. MR
imaging provides exquisite, versatile, and unique soft
tissue contrast, and allows for an effective evaluation
of a wide range of renal disorders. MR imaging
techniques with rapid acquisition times can bypass
many of the motion artifacts that previously posed
limitations to abdominal MR imaging and are now
widely available. MR imaging is especially attractive
in assessing renal-related disorders in children, in
women of childbearing age, and in patients with
renal insufficiency or renal allografts. This appeal
is the result of the lack of exposure to ionizing
radiation and the safety profile of the Food and
Drug Administrationapproved gadolinium contrast
agents. The latter includes an extraordinarily low rate
of anaphylactoid reactions and, in particular, the
ability to be used safely in the setting of pre-existent
renal insufficiency [13]. Renal MR imaging has
now evolved as an alternative or complementary
imaging modality to ultrasound, excretory urography,
and CT.
This article reviews the currently available
MR imaging strategies for the evaluation of the
renal-related disorders, and provides specific recom-
mendations to generate images with consistent diag-
nostic efficacy.
Overview: role of MR imaging in genitourologic
evaluations
Renal mass evaluation
The detection of kidney tumors has substantially
progressed over the last 15 years because of improved
imaging techniques [4], which have led to earlier
detection and improved survival. The incidence of
asymptomatic renal masses has increased up to 30%
during this time [5]. MR imaging has long played an
adjunctive role for the characterization of renal
masses that were indeterminate by ultrasound and
CT [3,6,7].
Recent improvements in MR imaging have
changed the playing field. Taken together with some
pitfalls that have been recognized with CT, such as
pseudoenhancement [8,9], MR imaging has emerged
as a nearly ideal technique for the detection, diagno-
sis, staging, and preoperative evaluation of renal
masses. Crescents of normal renal cortex separating
adjacent multiple cysts that appear as single lesions
with thick, enhancing septae on CT can be clarified
with the multiplanar capability, enhancement fea-
tures, and T2 signal characteristics of MR imaging
[7]. MR imaging also can stage the tumor at the time
of diagnosis, which facilitates an assessment of
prognosis and surgical planning. Parenchymal
lesions, venous extension, and adenopathy are all
clearly depicted.
The increased number of incidentally detected
renal masses, particularly smaller masses, has had
a substantial impact on the treatment of renal cell
carcinoma (RCC) over the last decade. The increased
reliance on nephron-sparing surgery, including less-
doi:10.1016/S0033-8389(03)00069-1
E-mail address: nrofsky@caregroup.harvard.edu
(N.M. Rofsky).
Radiol Clin N Am 41 (2003) 877907
invasive laparoscopic procedures, has maximized the
amount of remnant renal tissue without sacrificing
cancer control [10]. Indeed, studies suggest that
partial nephrectomy or wedge resection of local-
ized RCC yields cure rates similar to those obtained
with radical surgery [11], providing a long-term func-
tional advantage.
In this context, the imaging evaluation is particu-
larly important when planning complex nephron-
sparing treatments. A comprehensive gadolinium-
enhanced multiplanar MR imaging study integrates
all of the necessary information previously obtained
by conventional CT, angiography, venography, and
pyelography into a single preoperative test. Because
the growth rate of small renal tumors is slow or
nonexistent [12,13], an option for a watchful waiting
approach to small renal tumors has been suggested
[13,14]. MR imaging can serve as an effective tool
for follow-up of these small masses.
Urothelial tumor
The urothelium is a target tissue for carcinogens
that can lead to the development of transitional cell
carcinomas (TCCs). The urinary bladder is the most
common site of TCC. Any urothelial surface is sus-
ceptible, however, including the intrarenal collecting
system and the renal pelvis.
On MR imaging studies, urothelial tumors present
as enhancing, irregular fixed masses arising from any
urothelial surface, or focal wall thickening, either
eccentric or circumferential. TCC is usually confined
to the collecting system lumina, but lesions can
extend into the renal parenchyma, typically in an
infiltrative pattern that preserves the reniform shape.
The relatively slow growth of ureteral TCC allows for
gradual expansion of the ureteral lumen and is less
likely to produce acute symptoms [15]. MR urogra-
phy has been performed to demonstrate the dilated
urinary collecting systems associated with urothelial
tumors [16]. Technical details regarding MR urogra-
phy can be found elsewhere in this issue.
Renal artery evaluation
During the past decade, MR angiography has
evolved from an experimental technique into the
modality of choice for the noninvasive evaluation
of renovascular disease [17] and a serious alternative
to conventional angiography. The recent widespread
application of MR angiography for these indications
has been driven primarily by the advent of three-
dimensional contrast-enhanced MR angiography, a
robust technique with high accuracy [1820]. Superb
images of the renal arteries can be obtained, with
atherosclerotic lesions, occlusions, and aneurysms
well depicted.
Images similar in appearance to digital subtraction
angiography are generated with the use of postpro-
cessing techniques, such as maximum intensity pro-
jection (MIP) and volume rendering (VR). The spatial
resolution of MR angiography is lower than that of
digital subtraction angiography, but this is balanced
by its documented efficacy and safety. Indeed, the
consistently excellent correlation of MR angiography
with conventional angiography has generated an
increased reliance on this technique and may even
replace arteriography in most patients with suspected
renal artery stenosis [18,2135]. Furthermore, MR
angiography can be the only suitable option for
certain patients referred to assess a vascular etiology
for renal insufficiency.
The cross-sectional volumetric nature of con-
trast-enhanced MR angiography affords advantages
over conventional catheter angiography [19,36,37].
Although conventional angiography has been con-
sidered the gold standard, its limited projectional
views may cause obscuration of the proximal renal
arteries [38] and underestimation of en face ather-
omatous plaques. The volumetric MR angiography
enables true three-dimensional imaging, demon-
strating perspectives of renal artery stenoses that are
unattainable with the limited number of two-dimen-
sional projectional views inherent to conventional
angiography (Fig. 1) [19,21]. An additional benefit
of MR angiography is in detecting incidental but sig-
nificant pathologies, including parenchymal lesions
in the intra-abdominal organs and other potential
causes for renal insufficiency or hypertension (eg,
adrenal masses) [3941].
A unique capability of MR angiography is its
ability to supplement a vascular display with hemo-
dynamic and functional adjuncts [21,4245]. This
capability is particularly important for determining
the likelihood of achieving a favorable response to
revascularization [46]. The simultaneous acquisition
of angiographic images with time-resolved reno-
graphic data can provide a quantitative measurement
of renal perfusion [21,4750]. Associated findings,
such as poststenotic dilatation, delayed renal en-
hancement, and reduced renal parenchymal mass,
help to determine the hemodynamic significance of
a renal artery stenosis [51,52].
Quantitative assessments of renal function have
been pursued including MR phase-contrast flow
measurements, quantitative perfusion measurements
with intravascular contrast agents, MR renography,
and excreting contrast evaluations. By facilitating an
J. Zhang et al / Radiol Clin N Am 41 (2003) 877907 878
assessment of renal blood flow, perfusion, glomeru-
lar filtration rate, and functional impact in response
to pharmacologic challenge renal excretion, these
techniques can improve diagnostic specificity [42,
43,48,5356].
Current applications of renal MR angiography
range from detection of renal artery stenosis, planning
of renal revascularization, to preoperative evaluation
of potential transplant donors and recipients [57].
Contrast-enhanced MR angiography also is a reli-
Fig. 1. Renal artery stenosis in 63-year-old man with hypertension. (A) Coronal maximum intensity projections (MIP)
reconstruction of a three-dimensional fat-saturated T1-weighted gradient echo acquisition (TR = 3.8, TE = 1.9, FA = 25, slice
thickness = 4 mm, before interpolation) during the arterial phase after administration of a single dose of gadolinium (0.1 mmol/kg
body weight). There is mild stenosis in the proximal right renal artery (arrow). Note the atheromatous changes in the infrarenal
abdominal aorta (arrowheads). (B) Oblique axial view of the same MIP reconstruction as Fig. 1A shows a significant stenosis in
the proximal right renal artery secondary to an atheromatous plaque in the anterior wall of this vessel (arrow). Volumetric
acquisitions allow for MIP reconstructions that can be displayed in virtually any spatial orientation to demonstrate better the area
of interest. (C) Coronal image from a conventional angiogram in the same patient demonstrates only moderate stenosis of the
proximal right renal artery (arrow). Limited available projections in conventional angiography make difficult visualization of en
face plaques in the renal artery. Conventional angiography confirms the atheromatous changes in the infrarenal aorta with
ulcerated plaques (arrowheads).
able method in identifying postoperative vascular
complications and perfusion defects after renal re-
vascularization and in kidney allografts following
transplantation [19,5762]. Although reliable fol-
low-up can be obtained in patients following angio-
plasty, the results following stent placement can be
plagued by artificial signal loss from certain stent
materials [63].
Renal vein evaluation
The assessment of the renal veins is an important
component of the work-up of a patient with RCC.
The demonstration of tumor extension into the in-
ferior vena cava or into the right atrium affects
treatment planning and the surgical specialties that
potentially assist the urologist. MR imaging has
demonstrated an excellent depiction of tumor throm-
bus. It has been shown as a favorable technique for
determining the superior extent of tumor thrombus in
the inferior vena cava, especially in the region of the
right atrium [64,65].
This information potentially impacts the surgical
approach in cases where CT or ultrasound is equivo-
cal [6668]. The same technique used for three-
dimensional gadolinium-enhanced MR angiography
is ideal for noninvasive evaluation of the renal veins
and inferior vena cava (Fig. 2). Multiplanar refor-
mations from three-dimensional data sets are often
helpful in delineating tumor extent. Contrast-en-
hanced study with subtraction helps to differentiate
bland thrombus from enhancing tumor thrombus
(Fig. 3).
Imaging options
First discussed are broad imaging options. Then,
further details are provided guiding the selection and
recommendation of the possible approaches for opti-
mizing renal imaging. Tables 1 and 2 include the
particulars to help the user select specific MR imag-
ing parameters for robust diagnostic efficacy.
Breathhold imaging
In cooperative patients the most vexing problems
associated with MR imaging arise from artifacts
secondary to physiologic motion: respirations, car-
diac pulsations, and bowel peristalsis. Fast imaging
and single-shot pulse sequences in conjunction with
breathholding are the most effective techniques to
eliminate respiratory artifacts.
Suspended respiration is most reproducible in
end-expiration, a key consideration when subtraction
postprocessing is needed. End-expiratory breathhold-
ing is maximized by a brief coaching session in
which the patient is informed of the importance of
avoiding extremes in respiratory efforts and the goal
of achieving a constant lung volume at the end of
each expiration. The use of hyperventilatory prepa-
rations can facilitate the breathhold procedure. The
authors have found that two cycles of the command
breath in, breath out yield good results.
An additional benefit of the coaching session is
the ability to identify patients with the most limited
capacity to sustain a breathhold during a practice set
of commands. In these patients, the use of a nasal
cannula to administer oxygen greatly increases the
individuals breathhold ability [69]. Alternatively,
end-inspiration with or without oxygen supplemen-
tation can be used, and nonbreathhold strategies may
be needed.
Fig. 2. Left renal cell carcinoma with vein thrombosis. In the
presence of left renal vein thrombosis MR images provide
critical information that affect the decision for the surgical
approach. The superior mesenteric artery (SMA) is used as
an anatomic landmark for the midline. If the thrombus is
proximal to the SMA, a left flank approach is used. If
the thrombus extends beyond the SMA, a midline inci-
sion is preferred. Coronal three-dimensional fat-saturated
T1-weighted gradient echo image (TR = 4.5 TE = 1.9, FA =
12, slice thickness = 4 mm, before interpolation) during the
portal venous phase after administration of gadolinium
demonstrates an intraluminal filling defect in the left renal
vein (arrow) that does not extend beyond the SMA
(arrowhead). Findings were confirmed at surgery with left
flank approach.
Fig. 3. Left papillary renal cell carcinoma with renal vein thrombosis in a 51-year-old man presenting with pulmonary embolism
and stroke. Echocardiogram revealed a patent foramen ovale. (A) Coronal subtracted three-dimensional fat-saturated T1-
weighted gradient echo image (TR = 4.5 TE = 1.9, FA= 12, slice thickness = 4 mm, before interpolation) demonstrates a diffuse
infiltrative mass in the left kidney (arrows). (B) Coronal half-Fourier single-shot turbo spin echo (HASTE) image (TR = 1100,
TE = 64, FA = 130, slice thickness = 4 mm) of the abdomen shows complete filling of the left renal vein by tumoral thrombus
extending to the level of the inferior vena cava (IVC) (arrow). Note an area of susceptibility artifact immediately adjacent to the
tumor thrombus related to a previously placed IVC filter (white arrow). The SMA also is visualized (arrowhead). Tumor
thrombus was confirmed at surgery partially adhered to the IVC filter. Patient presented 6 months later with edema of both lower
extremities. A repeated MR imaging examination was obtained. (C) Coronal subtracted three-dimensional fat-saturated T1-
weighted gradient echo image (TR = 4.5 TE = 1.9, FA = 12, slice thickness = 4 mm, before interpolation) confirms the
thrombosis of the IVC. Note the heterogeneous enhancement consistent with tumoral thrombus (arrows) and nonenhancing areas
related to bland thrombus (arrowheads). IVC filter (thick white arrow).
One option that can be effective but is relatively
time consuming is the retrospective averaging of
individual breathholds [70]. Imaging strategies that
are relatively signal poor can be averaged to boost the
signal-to-noise ratio (SNR) and improve the image
quality [70]. The success of this retrospective averag-
ing is dependent on image co-registration and hence,
reproducible breathhold capability. Because of the
time constraints of this technique and the advent of
single-shot sequences, it is less commonly used.
Nonbreathhold imaging
Fast acquisitions
When breathhold imaging is not possible, fast
sequences, single-shot imaging, or respiratory cor-
rection techniques can be performed. For ventilated
patients, temporary suspension of the respirators often
yields motion-free images. As retroperitoneal struc-
tures the kidneys are somewhat restricted in their
motion, and renal images are less apt to be corrupted
by subtle movements.
Single-shot imaging provides a motion-insensitive
strategy because each slice is acquired in less than
1 second. The use of suspended respiration is not
required for image quality. When feasible, however, a
breathhold is recommended because it eliminates the
misregistration of slices and allows for the anatomy
to be demonstrated in a sequential manner.
Magnetization-prepared gradient-echo (MagPrep-
GRE) imaging is quite useful for generating fast
motion insensitive T1-weighted images. It allows
for very fast acquisition times on a per-slice basis,
eliminating the strict requirement for a breathhold to
achieve motion-free images. In this approach, images
are acquired sequentially, each image requiring less
Table 1
Sequences for renal mass protocol
Sequence Type Goals Additonal notes
1. Scout Multiplanar two-dimensional GRE Localization
2. Dual echo GRE Axial, two-dimensional GRE Characterize adrenal
lesions; help characterize
renal lesions
Can help detect susceptibility
when blooming noted in later echo
3. Sagittal T1 Three-dimensional GRE with
fat suppression
Lesion detection and
characterization
Can be oblique orientation;
separate acquisition of each kidney
4. Coronal T2 Two-dimensional half-Fourier,
single shot through kidneys
limited characterization
Plan off sagittals
5. Coronal T1 Three-dimensional GRE with
fat suppression
characterization; Vascular
evaluation
Precontrast and two postcontrast
scans (arterial and nephrographic
phases)
6. Delayed
post-gadolinium
(repeat sequences 2
and 3)
Three-dimensional GRE with
fat suppression
characterization
Subtract precontrast from
postcontrast
Table 2
Sequences for renal MRA protocol
Sequence Type Goals Additonal notes
1. Scout Multiplanar 2D GRE Localization
2. Dual echo GRE Axial, two-dimensional GRE Characterize adrenal lesions;
help characterize renal lesions
Can help detect susceptibility when
blooming noted in later echo
3. Coronal T2 Two-dimensional half-Fourier,
single shot through kidneys
Lesion detection and limited
characterization
4. High resolution
axial T1
fat suppression
Renal vascular evaluation (lesion
detection and characterization)
phases)
5. High resolution
coronal T1
fat suppression
Renal vascular evaluation,
including iliacs, celiac axis and
SMA origin (lesion detection
and characterization)
phases)
than 1.5 seconds per slice. Pulsation and motion
artifacts are largely eliminated [71,72].
With this approach is the potential for misregis-
tration among data sets. This can be seen when
attempting to compare in- and out-of-phase Mag-
PrepGRE images, typically obtained as separate
image sets. This presents a disadvantage compared
with breathhold dual-echo in- and out-of-phase
images. Furthermore, misregistration is often pres-
ent between unenhanced and enhanced sequences,
making subtraction postprocessing difficult. Another
disadvantage of MagPrepGRE is reduced SNR com-
pared with traditional T1-weighted breathhold GRE
sequences. Despite the recognized limitations, Mag-
PrepGRE imaging is a vital strategy for obtaining
diagnostic-quality T1-weighted images in those in-
dividuals in whom a breathhold cannot be success-
fully maintained.
The half-Fourier single-shot turbo spin echo
(HASTE) sequence provides rapid breathhold-in-
dependent T2-weighted imaging of the abdomen,
allowing for a better success rate in imaging uncoop-
erative, somnolent, or poor breathholding patients.
HASTE (Siemens Medical Solutions, Erlangen, Ger-
many) or single-shot fast spin echo (SSFSE, GE
Medical Systems, Milwaukee, WI) are preferred
as the motion-insensitive sequence for obtaining T2-
weighted images.
The use of fat-suppression can augment image
contrast and reduce artifacts caused by respiration
and other bulk motions. Many fat suppression strate-
gies increase the acquisition time but when applied
to motion insensitive nonbreathhold techniques can
offer improved image contrast and can identify the
presence of fat within a lesion. The authors have
relied on fat suppression with HASTE and SSFSE for
improving the image contrast with T2-weighted
sequences. To their knowledge there has not been a
successful implementation of fat suppression to Mag-
PrepGRE imaging.
Motion compensation strategies
A variety of means can be used to compensate for
in-plane motion artifacts resulting from respiration.
These techniques typically add considerable time to
the acquisition. Averaging strategies have been com-
monly used to compensate for respiratory motion.
The disadvantages of this technique include increased
scan time and obscured details. Image degradation is
most severe when breathing is erratic.
Perhaps more beneficial in those patients with
erratic breathing patterns is the use of intermittent
sampling of data at a relatively quiet time in the respi-
ratory cycle. This can be accomplished with respi-
ratory ordered-phase encoding [73] or respiratory
gating. Respiratory gating limits data acquisition to
end-expiration and is successful in restoring sharpness
and reducing ghost artifacts. Data are collected, how-
ever, only for a fraction of the respiratory cycle;
therefore, substantial increases in imaging time are
incurred. Respiratory triggering, however, initiates the
acquisition of an MR imaging section at a fixed point
of the respiratory cycle, restoring sharpness and re-
ducing ghosts. Unlike gating, triggering can be used to
produce an image at any phase of the respiratory cycle,
but it requires the use of longrepetitiontimes (TR) [74].
A practical technique that can benefit all the
previously mentioned approaches is the use of an
abdominal binder, an elastic garment that can be
wrapped around the abdomen. This device helps
minimize respiratory excursions and minimizes the
positional variations of structures caused by breathing
motion. Finally, more sophisticated techniques with
biofeedback strategies and navigator pulses are being
investigated but are not readily available in the
clinical environment.
An elaborate technique used to suppress respira-
tory motion in coronary imaging uses respiratory
gating with MR imaging navigators [7577]. This
technique has not yet been widely used for abdominal
imaging [78], although a recent report implementing
navigators for renal artery imaging suggests its po-
tential [79].
Role of coils and parallel imaging
The use of localized coils (ie, phased array torso
coil) is important to augment the SNR especially
when considering the high bandwidth sequences
necessary for contemporary rapid imaging. The use
of systems with high performance gradients and new
sequence designs has approached the limits on imag-
ing speed based on patient safety considerations. The
fastest techniques can result in peripheral nerve
stimulation, related to the maximum switching rates
of magnetic field gradients.
Parallel imaging or partially parallel imaging
techniques, such as sensitivity encoding, simulta-
neous acquisition of spatial harmonics, and array
spatial sensitivity encoding technique, can be used
to accelerate fast imaging sequences without increas-
ing gradient switching rates or radiofrequency (RF)
power deposition. This has been achieved by exploit-
ing spatial information inherent in the geometry of a
surface coil array [80,81]. The coil profiles are used
to generate missing k-space lines. This allows multi-
ple lines in k space to be generated simultaneously
for application of each phase-encoding gradient.
The recent emergence of clinically approved
whole-body 3-T systems makes the use of the body
coil without phased array coils feasible because the
SNR is twice as high at 3 T as at 1.5 T. High field
strength also extends the ultimate capabilities of
parallel imaging. Acceleration in parallel MR imag-
ing comes at a cost in SNR: the higher the accelera-
tion, the greater the SNR penalty.
The inherent SNR advantage at 3 T (resulting
from increased spin polarization) allows for greater
acceleration factors or higher degrees of resolution to
be pursued while maintaining image quality. More-
over, recent theoretical investigations [82,83] at the
authors center and elsewhere have predicted that the
combination of high field strength and parallel imag-
ing will afford SNR advantages above and beyond
those resulting from increased spin polarization. In
particular, the increased ability to focus radiofre-
quency energy at high RF frequencies has been
shown to result in an improved capacity for spatial
encoding with coil arrays, and hence in higher SNR
and higher achievable accelerations for high-field
parallel imaging.
T2-weighted imaging
Clinical applications
Normal kidney has a relatively long T2 time,
yielding a higher SI relative to liver and many other
soft tissues but close in SI to that of the spleen.
T2-weighted imaging is most helpful in distinguish-
ing simple cysts from other lesions. Simple cysts
have much longer relaxation times than renal paren-
chyma and readily detected as high signal intensity
lesions on T2-weighted imaging techniques. Septa-
tions can be depicted readily within cysts (Fig. 4) and
those cysts complicated by hemorrhage or infection
may be heterogeneous or low in SI on T2-weighted
images. Angiomyolipoma (AML), hematoma, aneu-
rysm, and infectious mass can all demonstrate het-
erogeneous T2 signal intensities.
Renal cell carcinoma is variable in signal on
T2-weighted images [84]. Hemorrhagic products in
malignant tumors cause heterogeneous T2 signal
characteristics, but cannot be distinguished reliably
from benign cysts containing hemorrhage. Defini-
tive characterization depends on the demonstration
of enhancement within a lesion to identify a vascular
supply; that demonstration excludes a simple cyst
(Fig. 5).
Spin echo sequences
In conventional spin echo imaging only one phase-
encoding step per TR is used to encode spatial infor-
mation. The associated acquisition times exceed the
possibility for breathhold imaging. These sequences
clearly benefit from the previously mentioned strate-
gies of suppressing motion-induced artifacts. Regard-
less, motion-induced blurring and ghost artifacts
remain a problem. Fat suppression techniques can
augment image contrast and reduce motion arti-
Fig. 4. Renal cyst with multiple septations in 88-year-old man with cystic lesion in the right kidney on prior abdominal CT
performed for staging of bladder carcinoma. (A) Cor T2. Coronal fat saturated HASTE image (TR = 1100, TE = 64, FA = 130,
slice thickness = 4 mm) of the abdomen shows a large cyst in the right kidney with multiple septations (arrow). A smaller cyst is
noted in the medial aspect of the upper pole of the right kidney (arrowhead). (B) Cor T2 subs 2. Coronal three-dimensional fat-
saturated T1-weighted gradient echo image (TR = 4.5 TE = 1.9, FA = 12, slice thickness = 4 mm, before interpolation) after
administration of gadolinium demonstrates the lack of enhancement confirming the cystic nature of the lesion. A thin septation is
noted in the superior aspect of the cyst (arrowhead). A second small nonenhancing cyst also is noted in the upper pole of the
right kidney (arrow).
facts caused by respiration, but further increase ac-
quisition time.
Echo-train imaging
Echo-train imaging is generically referred to as
rapid acquisition with relaxation enhancement
sequences [85]. These techniques commonly use
vendor-related acronyms, such as fast spin echo
and turbo spin echo. This family of sequences is
characterized by the application of a train of multiple
phase-encoding gradients for a given TR, obtaining
T2-weighted images in less time than conventional
spin echo imaging. The length of the echo train is
proportional to the reduction in scan time that can be
achieved. Longer echo-trains can be used to obtain
T2-weighted images in the time frame of a breath-
hold, which have been shown to improve results
[86,87]. Strong gradient systems benefit echo-train
imaging by minimizing interecho spacing, which in
turn reduces artifacts.
The effective echo time is determined by the echo
times of the lowest phase-encoding gradients among
the echo train (the center of k space) and provides the
Fig. 5. Coexistent papillary renal cell carcinoma and hemorrhagic cyst in a 65-year-old man with esophageal carcinoma. Renal
mass incidentally noted on CT scan. (A) Coronal HASTE image (TR = 1100, TE = 64, FA = 130, slice thickness = 4 mm) at the
level of the kidneys shows two lesions in the right kidney, one in the superior (arrow) pole, and one in the inferior (arrowhead)
pole. The lesion in the upper pole is slightly hypointense compared with the renal parenchyma. The lesion in the inferior pole is
isointense to the renal parenchyma. Based on these findings, differentiation between cyst and solid tumor cannot be achieved.
(B) Unenhanced, three-dimensional fat-saturated T1-weighted gradient echo image (TR = 4.5 TE = 1.9, FA = 12, slice
thickness = 4 mm, before interpolation) shows the large lesion in the superior pole of the right kidney with similar signal
intensity than the renal medulla. This finding does not help in its characterization. Note that the lesion in the inferior pole
demonstrates high signal intensity suggesting hemorrhage. (C) Gadolinium-enhanced, three-dimensional fat-saturated
T1-weighted gradient echo image (TR = 4.5 TE = 1.9, FA = 12, slice thickness = 4 mm, before interpolation) during the
venous phase shows both lesions with signal intensity lower than that of the enhancing renal parenchyma. Determination of
enhancement of these lesions is difficult based on subjective impression alone. (D) Coronal subtracted three-dimensional fat-
saturated T1-weighted gradient echo image (venous phase [Fig. 5C] minus precontrast [Fig. 5B]) confirms the enhancement of
the lesion in the superior pole (arrow) of the right kidney. In contrast, the inferior pole lesion appears black (arrowhead)
because of the lack of enhancement. The lesions were confirmed to be a papillary RCC in the upper pole of the right kidney
and a hemorrhagic cyst in the inferior pole at pathology.
dominant image contrast. Fat demonstrates higher
signal intensity with echo-train techniques compared
with conventional T2-weighted SE sequences. Selec-
tion of the effective echo time and the addition of fat-
suppression, as needed, maximize image contrast
with echo-train imaging.
As mentioned previously, nonbreathhold, echo-
train, T2-weighted imaging can be improved by the
use of fat suppression or respiratory triggering for
patients with limited breathhold capacity. An alterna-
tive motion reduction strategy is the placement of a
saturation band over the anterior abdominal wall
subcutaneous fat. This nullifies signal from the tissue
most responsible for propagating respiratory artifacts
into the abdominal cavity.
Half-Fourier T2 weighted imaging
Half-Fourier reconstruction is another modifica-
tion that can be added to echo-train imaging further to
decrease the acquisition time (eg, HASTE, SSFSE).
HASTE is a single-shot technique that acquires just
over half of k-space in one echo-train. The symmetry
of k space allows for mathematic reconstruction of an
image based on that partial acquisition [88].
Because data can be acquired in less than a
second on a per-slice basis, HASTE is very helpful
in patients unable to breathhold or when a rapid
survey is needed. Compared with turbo spin echo,
HASTE can have a shorter TE because the center
of k-space can be acquired near the start of the
echo-train [89].
Drawbacks of half-Fourier imaging include
poorer SNRs than those found in turbo spin echo,
and reduced contrast-to-noise ratio compared with
conventional T2-weighted spin echo or sequences
using shorter echo-trains. In addition, blurring is seen
as a result of T2 decay during the long echo-train.
These render HASTE less sensitive for small, low-
contrast lesions.
The authors use this technique to survey for the
presence of focal lesions and as a rapid assessment
for hydronephrosis or collecting system filling de-
fects. In the authors experience HASTE techniques
can characterize cysts when there is uniform, mark-
edly hyperintense signal without mural nodularity
or complicated internal septations, in essence serving
much as an ultrasound for assessment of renal le-
sions. HASTE also offers a rapid survey for pa-
thology elsewhere in the abdomen and renders
excellent anatomic details. Coronal HASTE has
become a routine component for the authors renal
imaging and for upper abdominal imaging in general.
T1-weighted imaging
Clinical applications
In the normal kidney the cortex is slightly higher
in signal intensity than the medulla on strongly
T1-weighted sequences and the medulla has a similar
signal intensity compared with muscle. Most cysts
have a long T1, and often appear lower in signal
intensity than normal renal parenchyma. Cysts com-
plicated by hemorrhage or containing proteinaceous
fluid may demonstrate increased signal intensity
because of T1 shortening effects from blood products
or protein and may show heterogeneous signal fea-
tures or fluid-fluid levels (Fig. 6).
Most of the solid renal masses other than AML
demonstrate signal intensity that is slightly lower
compared with renal cortex on T1-weighted images.
Macroscopic fat, found in most AMLs, has a short T1
and exhibits a relatively high signal on T1-weighted
images compared with background parenchyma. High
signal on T1-weighted images can also be caused by
paramagnetic effects, such as intralesional hemorrhage
(cyst, AML, and RCC); melanin-containing lesions
(metastases from malignant melanoma); and proteina-
ceous mucin-containing lesions (complicated cyst and
abscess). The presence of macroscopic fat is best
confirmed with the use of fat-saturation techniques.
Some AMLs have less fatty component, and
may be difficult to be differentiated from other solid
renal lesions. In this regard chemical-shift imaging
(in-phase and opposed-phase gradient echo [GRE]
imaging) is an important tool to detect microscopic,
fractional intravoxel lipid, with certain caveats as
described later in this manuscript.
GRE sequences
The GRE techniques for T1-weighted imaging
include either multishot or single-shot strategies.
The most widely used and efficacious GRE technique
is the multishot, spoiled approach. Such sequences as
fast spoiled GRE sequences (GE Medical Systems)
and fast low-angle shot sequences (Siemens Medical
Systems), use short TR and TE values with a flip
angle of 70 to 90 degrees and can provide full
coverage of the kidney in one 18- to 23-second
breathhold. These acquisitions offer good SNR, reg-
ular section spacing, and minimize respiratory-related
artifacts. To facilitate the breathhold while preserving
SNR and optimal contrast, a TR of 120 to 200 mil-
liseconds is advised. The speed of these sequences
allows for dynamic contrast-enhanced MR imaging
with or without fat suppression [90,91].
It is the comparison of precontrast and delayed
(nephrographic) postcontrast T1-weighted images that
is key to the detection and characterization of renal
lesions (Fig. 7) [3,92,93]. Tumor extension into ve-
nous structures is often readily determined on delayed
postcontrast imaging but can also be diagnosed by
using a flow-sensitive GRE sequence to distinguish
between flowing blood and tumor thrombus [94].
MagPrepGRE imaging is vital for providing diag-
nostic-quality T1-weigthed images in patients with a
Fig. 6. Fluid-fluid level in hemorrhagic cyst in 64-year-old man with prostate cancer. (A) Axial T1-weighted in-phase gradient
echo image (TR = 160, TE = 5.3, FA = 90, slice thickness = 8 mm) at the level of the kidneys shows a right renal lesion with a
fluid-fluid level (arrow). Note the hyperintense blood products layering in the dependent portion of the lesion. (B) Contrast-
enhanced three-dimensional fat-saturated T1-weighted gradient echo image (TR = 4.5 TE = 1.9, FA= 12, slice thickness = 4 mm,
before interpolation) during the delayed venous phase shows homogenous enhancement of both kidneys. Hyperintense blood
products within the cyst can be interpreted erroneously as a focus of enhancement (arrow). (C) Axial subtracted (postcontrast
minus precontrast) three-dimensional fat-saturated T1-weighted gradient echo image (TR = 4.5 TE = 1.9, FA = 12, slice thick-
ness = 4 mm, before interpolation) demonstrates lack of enhancement in the right renal cyst (arrow).
limited breathhold capacity. The magnetization-pre-
pared sequence is structured so that data acquisition
occurs during the T1 recovery of tissues following a
180-degree inversion pulse. The inversion pulse pro-
vides flexible image contrast [95]. When a section-
selective 180-degree inversion pulse is used, only the
protons of the specific section are inverted. This
results in images in which the vessels are bright
and lesions are dark. The authors use a nonselective
inversion pulse, which, with an appropriate TI time,
yields dark blood and excellent T1 contrast. With
this technique, pulsation artifacts are eliminated and
enhancement of vessels or tumor thrombus within
veins can be readily appreciated.
In-phase and opposed phase
The GRE images can be obtained with specific TE
values such that protons from fat and water are either
in-phase or out-of-phase with one another [96]. When
fat and water are present within a voxel, a loss of
signal intensity is noted when the opposed-phase
images are compared with the in-phase images.
Compared with frequency-selected fat suppression,
opposed-phase technique is sensitive for detecting
intracellular lipid. Renal and adrenal masses may
contain focal fat (angiomyolipomas and myelolipo-
mas, respectively) or diffuse, intracellular lipid (clear
cell renal carcinomas and adenomas, respectively)
Fig. 7. Characterization of renal mass with precontrast and postcontrast T1-weighted images in 69-year-old woman with gross
hematuria and right flank pain. (A) Unenhanced, coronal three-dimensional fat-saturated T1-weighted gradient echo image (TR =
4.5 TE = 1.9, FA= 12, slice thickness = 4 mm, before interpolation). A large mass is noted in the inferior pole of the right kidney.
The hypointense center (arrow) suggests necrosis, whereas areas of high signal intensity in the dependent aspect of the mass
(arrowhead) are consistent with hemorrhage. (B) Coronal three-dimensional fat-saturated T1-weighted gradient echo image
(TR = 4.5 TE = 1.9, FA = 12, slice thickness = 4 mm, before interpolation) during the arterial phase after administration of
gadolinium shows early enhancement of the peripheral rim of tumor (arrows). There is suggestion of enhancing septae in the
center of the lesion (arrowhead). (C) Coronal three-dimensional fat-saturated T1-weighted gradient echo image (VIBE) (TR =
4.5 TE = 1.9, FA = 12, slice thickness = 4 mm, before interpolation) during the venous phase after administration of gadolinium
better demonstrates the irregular enhancing septae within the mass (arrow) and areas of necrosis. At nephrectomy, a clear cell
RCC with cystic and hemorrhagic degeneration was found.
Fig. 8. Microscopic and macroscopic fat in angiomyolipoma in 59-year-old woman with renal mass incidentally noted on
ultrasound. (A) Axial T1-weighted in-phase gradient echo image (TR = 160, TE = 5.3, FA= 90, slice thickness = 8 mm) shows a
slightly heterogeneous hyperintense mass in the left kidney (arrow). (B) Axial T1-weighted out-of-phase gradient echo image
(TR = 160, TE = 2.7, FA = 90, slice thickness = 8 mm) at the same level as Fig. 8A demonstrates decreased signal intensity
within near the entire mass. This finding is consistent with the presence of fractional intravoxel fat and water (microscopic fat).
Central hyperintense areas that do not decrease in signal intensity (arrowhead) are likely caused by a focus of macroscopic fat.
(C) Unenhanced, coronal three-dimensional fat-saturated T1-weighted gradient echo image (TR = 4.5 TE = 1.9, FA = 12, slice
thickness = 4 mm, before interpolation) shows the mass in the left kidney with intermediate signal intensity. Fat saturation is
achieved by applying a frequency selective pulse. Note focal areas of low signal intensity consistent with saturation of the
macroscopic fat within the mass (arrow). The presence of macroscopic fat is virtually diagnostic of AML. (D) Coronal three-
dimensional fat-saturated T1-weighted gradient echo image (TR = 4.5 TE = 1.9, FA = 12, slice thickness = 4 mm, before
interpolation) after administration of gadolinium demonstrates enhancement within the lesion confirming its solid and
heterogeneous nature (arrow).
[94,97,98]. AML may contain both macroscopic fat
and intracellular lipid (Fig. 8).
On opposed-phase images, some clear cell car-
cinomas show relative focal or diffuse loss of
signal intensity because of the presence of intracel-
lular fat (Fig. 9). In renal masses, loss of signal
intensity on the opposed phase sequence is not
specific for angiomyolipoma [97,99]. Chemically
selective fat saturation techniques are primarily
used for identifying masses containing macroscopic
fat, such as AMLs and adrenal myelolipomas. On
opposed-phased GRE images a boundary chemical
Fig. 9. Microscopic fat in renal cell carcinoma (RCC) in a 58-year-old man with right renal mass found on CT scan performed as
a work-up of varicocele. Histopathologic analysis after nephrectomy revealed RCC, clear cell type. (A) Axial T1-weighted
gradient echo in-phase image (TR = 160, TE = 5.3, FA = 90, slice thickness = 8 mm) demonstrates a large mass in the right
kidney. Note the heterogenous appearance with low signal intensity center (arrow) and a peripheral slightly hyperintense rim
(arrowheads). (B) Axial T1-weighted gradient echo out-of-phase image (TR = 160, TE = 2.7, FA = 90, slice thickness = 8 mm)
shows decreased signal in the peripheral rim (arrowheads), which now is isointense to the central area. This finding is consistent
with the presence of fractional intravoxel fat (microscopic fat). (C) Coronal three-dimensional fat-saturated T1-weighted gradient
echo image (TR = 4.5 TE = 1.9, FA = 12, slice thickness = 4 mm, before interpolation) during the arterial phase after
administration of gadolinium confirms the solid nature of the mass with a thick peripheral rim of enhancing tumor (arrowheads)
and central necrosis (arrow).
shift artifact is frequently present surrounding the
fatty components of these masses, a finding that
can be helpful for characterizing these lesions
(Fig. 10).
Perinephric involvement of tumor can also be
detected using opposed-phase GRE images because
of the artificial accentuation of renal contours from
the black line at the renal-retroperitoneal fat inter-
face, established by chemical shift artifact [94]. In
the authors experience, however, it is the negative
predictive value, seen by the preservation of the
black line between adjacent tissues, which has the
most value in excluding contiguous involvement of
structures. When a mass extends beyond the renal
capsule and abuts an adjacent organ the black line
may be lost without invasion of that adjacent organ.
At 1.5 T, a GRE sequence with a TE of 4.4 milli-
seconds yields an in-phase image, whereas a TE of
2.2 milliseconds yields an opposed-phase image.
Some manufacturers use sequences that, despite
being slightly off the optimal TE values (eg, 5.3 milli-
seconds and 2.7 milliseconds for in- and out-of-
phase, respectively), are still able to portray the
desired imaging features.
The in-phase and opposed-phase images can be
acquired simultaneously in the multisection mode.
This is accomplished by acquiring two echoes per
excitation at different echo times and reconstructing
the data as separate image sets. Because this dual-
echo, in-phase, opposed-phase sequence can be
obtained during a breathhold, respiratory misregistra-
tion between in-phase and opposed-phase images is
eliminated, which facilitates a comparison of the two
image sets.
A complete renal examination requires the use
of T1-weighted images with chemically selective fat
saturation in addition to in- and opposed-phase
imaging to capture the specificity of fat suppression
rather than relying on inferences to determine a
mass containing bulk fat.
Fig. 10. Characterization of angiomyolipoma using chemical shift artifact in 57-year-old woman with hypertension. Left renal
lesion incidentally noted on MR angiography of the abdomen for evaluation of renal artery stenosis. (A) Axial T1-weighted
in-phase gradient echo image (TR = 160, TE = 5.3, FA = 90, slice thickness = 8 mm) shows a hyperintense lesion in the left
kidney (arrow). (B) Axial T1-weighted out-of-phase gradient echo image (TR = 160, TE = 2.7, FA= 90, slice thickness = 8 mm)
demonstrates a boundary chemical shift artifact at the interface of the lesion and the surrounding renal parenchyma caused by the
coexistence of intravoxel fat and water protons (arrow).
Spin echo sequences
Formerly the standard for T1-weighted imaging
of the body, spin echo sequences should be relegated
to systems unable to achieve good-quality breathhold
imaging. These systems clearly benefit from the
previously mentioned strategies aimed at suppressing
motion-induced artifacts, but motion-induced blur-
ring of contours remains a problem. For spin echo
T1-weighted imaging either a standard spin echo se-
quence with a short TR (eg, 400 to 600 milliseconds)
or a short echo-train (eg, 3) turbo spin echo sequence
with multiple signal averages is generally used, but
breathhold imaging is difficult to accomplish.
The use of half-Fourier reconstructions with spin
echo sequences can yield good-quality breathhold
images while minimizing susceptibility artifacts.
The rapid acquisition spin echo technique combines
a relatively short repetition time, a short echo time,
and half-Fourier data sampling [100]. This spin echo
technique is less vulnerable than GRE sequences to
susceptibility artifacts and can be beneficial following
surgery with metallic clips. Rapid acquisition spin
echo generally requires two breathholds to achieve
full anatomic coverage and suffers from relatively
low SNRs. The latter can be largely overcome with
the use of a phased-array body coil [101].
Two- versus three-dimensional T1-weighted spoiled
GRE sequences
Fast T1-weighted imaging with GRE sequences
is the cornerstone of renal imaging. For two-dimen-
sional breathhold imaging in the abdomen, the quality
and efficacy of imaging are limited by the need to
acquire enough sections to cover a relatively large
region, typically 160 to 200 mm. This must be accom-
plished with the finite number of sections that can be
obtained in less than 25 seconds and requires the use
of relatively thick sections (8 to 10 mm) and interslice
gaps. Alternatively, two separate image sets have to be
obtained to achieve adequate anatomic coverage.
With two-dimensional GRE imaging, smaller
lesions can be missed or insufficiently characterized
because of partial volume averaging and low con-
trast-to-noise ratio. The short acquisition times may
also place other serious trade-offs on imaging, such
as increasing anatomic coverage at the expense of
decreased spatial resolution, or requiring the use of
higher bandwidths that reduce the SNR. In addition,
some fat-saturation methods, which can improve
contrast-to-noise ratios on contrast-enhanced images,
require additional imaging time.
Three-dimensional Fourier transform imaging has
advantages over two-dimensional imaging. Properly
structured three-dimensional GRE sequences, such as
volumetric interpolated breathhold examination (Sie-
mens Medical Solutions) or fast acquisition with
multiphase Efgre3d (GE Medical Systems), have
the capacity to provide thin sections, no gaps, fat
saturation, higher SNR ratios, and comparable image
contrast in a breathhold time frame [102].
Breathhold contrast material enhanced three-
dimensional fast spoiled GRE sequences are crucial
for the evaluation of renal vascular structures [103].
The volumetric three-dimensional sequence, used for
combined parenchymal and vascular imaging, is
modified from sequences originally designed for
gadolinium-enhanced angiography [102]. Key attri-
butes of the sequence geared toward optimized
parenchymal evaluations include the use of reduced
flip angle (10 to 15 degrees) and a symmetric or full
echo for readout. When appropriately thin sections
yield pixel sizes approaching nearly isotropic resolu-
tion and accurate timing methods are used, a single
data set generates high-quality images of the paren-
chyma as well as MR angiography (Fig. 11).
Furthermore, the thin sections that can be acquired
with three-dimensional imaging yield a data set that is
amenable to meaningful multiplanar reconstructions,
allowing images to be reformatted in standard or-
thogonal planes, oblique axes, and curved planes.
This can facilitate characterization of lesions that may
be difficult to evaluate on axial images. Multiplanar
reconstructions of volumetric data are also useful for
pretherapeutic planning including surgery, emboliza-
tion, radiofrequency ablation, and cryoablation.
A useful nuance that benefits three-dimensional
coronal acquisitions and coronal acquisitions in gen-
eral is the placement of the patients arms outside the
imaged field of view. This avoids aliasing artifacts
and allows for the smallest possible field of view and
the highest resolution in a given acquisition time. The
patients arms can be elevated with towels or cush-
ions. Alternatively, the patients arms can be raised
over their head.
Technical considerations for three-dimensional MR
angiography
Dynamic coronal three-dimensional imaging is
the fundamental technique for MR angiography of
the renal arteries. An excellent approach uses high
spatial resolution, small field of view, axial three-
dimensional contrast-enhanced MR angiography of
the renal arteries followed several minutes later by the
more standard large field of view, three-dimensional,
coronal contrast-enhanced MR angiography, the latter
including the distal aorta and iliac arteries [104].
With dynamic three-dimensional Fourier imaging,
the order in which data are acquired has a substantial
impact in imaging considerations [105,106]. The
matrix into which data are filled in MR imaging is
typically referred to as k space. K space, or Fourier
space, does not map to the image pixel by pixel.
Rather, the information within k space reflects the
spatial frequency features of the image. The low spa-
tial frequency information, in the center of k space,
dominates image contrast, whereas the higher spatial
Fig. 11. Seventy-year-old man with incidental renal mass on CT scan. (A) Coronal three-dimensional fat-saturated T1-weighted
gradient echo image in the venous phase after administration of gadolinium. The use of a low flip angle and full echo allows for
a good visualization of the renal parenchyma. A large enhancing mass is visualized in the inferior pole of the left kidney (arrow).
(B) Coronal source image from the same acquisition as Fig. 11A at a slightly anterior location. Note the excellent visualization of
the enhancing normal left renal vein (arrow). (C) Maximum intensity projection from the subtracted coronal data set acquired
during the arterial phase. There is excellent visualization of both renal arteries (arrows) using the technique tailored for
evaluation of both vascular and parenchymal details.
frequency data, at the periphery of k space, determine
image detail [107]. To obtain an arterial-phase image
in which arteries are bright and veins are dark, it is
essential that the central k-space data (ie, the low
spatial frequency data) are acquired while the gado-
linium concentration in the arteries is high but rela-
tively lower in the veins.
The standard mode of filling k space is a se-
quential mode in which the most negative spatial
frequency component is collected first, with each
subsequent point advancing through the zero spatial
frequency component and continuing to the most
positive spatial frequency component. With centric
acquisitions, the zero spatial frequency component
in the xy plane is acquired first, followed by pro-
gressively higher spatial frequency components,
alternating between positive and negative.
Elliptic-centric filling of k space is an extension of
centric ordering. It first fills the center of k space in
the xy and z planes (in-plane and through-plane axes,
respectively). In so doing the center portion of k space
is effectively compressed and filled in a very short
time. This approach has been used effectively for
renal MR angiography [104].
If the center of k space is inadvertently acquired
too early, severe artifacts can result, particularly with
centric acquisitions [105,108]. These artifacts are
manifested as ringing and widening of the apparent
lumen. Centric acquisitions, however, offer some
advantages. These techniques are more robust to
breathing artifacts in poor breathholders because the
motion during the center of k space has the greatest
impact [109]; patients who can only hold their breath
for a short time (ie, 6 seconds) have less breathing
artifact in centrically ordered three-dimensional
acquisitions as compared with linear ordered three-
dimensional acquisitions. Furthermore, an earlier
acquisition of the center of k space minimizes paren-
chymal enhancement, improving the delineation of
more distant renal vessels in the hilum and early
intraparenchymal branches.
Flow-sensitive imaging
The intrinsic sensitivity of MR imaging to flowing
spins affords the visualization of vessels, and an
assessment of flow both qualitatively and quantita-
tively. Flow-sensitive imaging can be used to com-
plement the morphologic images of contrast-enhanced
MR angiography by providing hemodynamic in-
formation [37]. Compared with three-dimensional
contrast-enhanced MR angiography, however, flow-
sensitive techniques are more prone to overestimat-
ing the severity of disease. For assessing the renal
arteries they are usually reserved for detection of
main renal artery stenoses and as a noninvasive func-
tional assessment.
Time of flight
Time of flight was formerly a standard technique
for vascular imaging in the body. Although stenoses
of the proximal renal arteries can be detected with
this technique, accessory renal arteries of small cali-
ber and distal branches of renal arteries are not
adequately displayed [110]. Other disadvantages of
this technique compared with gadolinium-enhanced
three-dimensional MR angiography include degrada-
tion from in-plane saturation and motion related
artifacts. Gadolinium-enhanced breathhold three-
dimensional technique improves the evaluation of
vascular anatomy and is more reliable for visual-
izing accessory renal arteries [24,111]. The emer-
gence of gadolinium-enhanced three-dimensional
MR angiography has virtually eliminated non
contrast-enhanced time of flight for abdominal MR
angiography. For renal imaging time of flight can be
helpful to clarify subtle intraluminal filling defects
within the veins where flow artifacts still can affect
gadolinium MR angiography. For this purpose ECG-
triggered cine sequences are particularly valuable.
Phase contrast
Phase-contrast MR imaging is a flow-based tech-
nique exploiting the relationship between moving
protons and their response to the application of
gradients. It has not been widely accepted as a
technique for generating MR angiography in the
abdomen, primarily because of lengthy acquisition
times, artifacts, and difficulty in selecting the proper
velocity-encoding gradient. Three-dimensional phase
contrast has served a useful function as an adjunct in
MR angiography studies. Proton dephasing and the re-
sultant loss in signal intensity can be seen in the pres-
ence of hemodynamically significant stenoses [36].
The three-dimensional phase-contrast MR angiog-
raphy combined with renal gadolinium MR angiog-
raphy can decrease the number of false-positive
interpretations [43,112,113].
The phase-contrast sequence has also been used
for quantitative measurement of renal arterial flow in
evaluation of renal artery stenosis [44,114]. Velocity
waveforms in the renal artery, akin to Doppler sono-
graphic tracings, can be measured noninvasively
using phase-contrast velocity-encoded MR imaging
[115,116]. The combined approach of three-dimen-
sional gadolinium MR angiography and cine PC flow
measurement was reported to reveal excellent inter-
observer variability and almost perfect intermodality
agreement with digital subtraction angiography
[26,117].
With faster acquisition times, several phase-con-
trast velocity measurements may be obtained in the
same setting as routine MR angiography. The advan-
tages of MR phase-contrast technique over sono-
graphic approaches are it is not limited by patient
body habitus, it is not adversely impacted by the
presence of bowel gas, and the location and angle of
velocity measurements using MR imaging technique
are also more easily achieved. The disadvantages
include the lower temporal resolution compared with
Doppler sonography, the lower spatial resolution
precluding the evaluation of small intrarenal vessels
[110,113], and reliance on consistent cardiac rhythms
for ECG triggering [115].
Turbulent or nonlaminar flow, which may be
caused by tortuous vessels or abrupt change of lumi-
nal diameter, can lead to the dissipation of phase
coherence, which manifests as signal loss on all
MR imaging techniques including phase contrast
[110,118]. This may cause false-positive findings but
can often be clarified by using gadolinium-enhanced
three-dimensional MR angiography [34,115].
Contrast-enhanced dynamic imaging
Clinical application
The presence of contrast enhancement is the most
crucial criterion for distinguishing solid renal lesions
from cysts. Image acquisition in various vascular
phases after intravenous administration of a single
bolus of contrast material refines the diagnostic
Fig. 12. Multilocular cystic renal cell carcinoma (RCC) in a 41-year-old man with left renal mass incidentally noted on work-up
of right upper quadrant discomfort. (A) Coronal fat-saturated HASTE image (TR = 1100, TE = 64, FA = 130, slice thickness =
4 mm) at the level of the kidneys. A large cystic lesion is noted in the inferior pole of the left kidney. Note multiple thick
septations within the lesion (arrow). (B) Coronal subtracted three-dimensional fat-saturated T1-weighted gradient echo image
(venous phase, unenhanced). The enhancing septae are readily seen. Note an enhancing nodule at the confluence of multiple
septations (arrow). (C) Coronal subtracted three-dimensional fat-saturated T1-weighted gradient echo image (venous phase,
unenhanced) at a slightly different level than Fig. 12B. Multiple irregular enhancing septae are visualized within the lesion
(arrows). Histopathologic analysis was diagnostic for multilocular cystic RCC.
work-up of renal masses. Dynamic contrast-enhanced
studies usually allow the detection of even small
enhancing solid areas within a cystic renal mass
(Fig. 12) [94].
The scanning protocol should include unenhanced
MR imaging followed by imaging during the arterial,
venous, and nephrographic phases. The arterial phase
is the most important for depicting arterial anatomy
and in identifying hypertrophied columns of Bertin as
pseudotumors (Fig. 13).
The venous phase is essential for imaging the
renal veins for possible tumoral extension and the
parenchymal organs for potential metastases, whereas
the nephrographic phase is the most sensitive for
tumoral detection. The authors perform three-dimen-
sional GRE T1-weighted sequences in a multiphase
series. The first acquisition is timed to capture the
arterial phase; a second acquisition is initiated 20 sec-
onds after the first and a third acquisition is initiated
30 seconds after the previous. Alternatively, one can
acquire only two data sets, the first timed for the
arterial phase and the second initiated 35 seconds
after the first.
With use of fast GRE sequences, dynamic con-
trast-enhanced MR imaging with or without fat sup-
pression has been used to characterize renal lesions
by means of a qualitative or quantitative analysis of
signal intensity changes over time [90,91]. Qualita-
tive assessment of enhancement works quite well
provided that the same sequences are used for pre-
contrast and postcontrast imaging [6,14].
The determination of subtle enhancement can
benefit from a quantitative approach or subtraction
imaging [14,119]. Care should be exercised when
using quantitative criteria for characterization. There
is no standardized scale for signal intensity values
and the degree of precontrast and postcontrast
changes varies among sequences. For quantitative
evaluations it is important to ensure that unen-
hanced and enhanced sequences are identical, includ-
Fig. 13. Pseudotumor in a 36-year-old man with right upper quadrant discomfort. (A) Left sagittal ultrasonographic image shows a
hypoechoic mass in the mid portion of the kidney (arrow). (B) Coronal three-dimensional fat-saturated T1-weighted gradient echo
image (TR = 4.5 TE = 1.9, FA= 12, slice thickness = 4 mm, before interpolation) during the arterial phase after administration of
gadolinium. There is normal enhancement of the left kidney. There is normal corticomedullary enhancement in the region of
the suspected mass (arrow). (C) Coronal image from a dynamic data set using scanning parameters from Fig. 13B acquired
30 seconds after the arterial phase confirms the normal enhancement of the pseudomass (arrow), which continues to track with the
cortex and medulla. (D) Coronal image from a dynamic data set using scanning parameters from Fig. 13B acquired 90 seconds
after the arterial phase confirms the normal enhancement of the pseudomass (arrow), which follows normal renal parenchyma.
ing the use of matched receiver gain and attenua-
tion values.
Renal cell carcinoma is the most common ma-
lignancy of the kidneys. It is typically hypovascular
compared with the renal cortex but on occasion can
be hypervascular. Other malignancies, such as TCC,
metastatic lesions, and renal lymphoma also en-
hance. It is important to note that the presence of
contrast enhancement does not always indicate
malignancy. A host of solid benign renal tumors
and inflammatory masses also enhance. Of these,
AML and oncocytomas are the most common.
AML has an early peak enhancement, although
these tumors remain hypointense compared with
renal cortex, followed by a subsequent vascular
washout [90].
Fig. 14. Metastatic transitional cell carcinoma (TCC) in a 53-year-old man with painless hematuria. (A) Coronal HASTE image at
the level of the kidneys shows severe hydronephrosis of the right kidney and target-appearing metastatic lesions to the liver
(arrows). No renal mass is detected based on this image. (B) Coronal three-dimensional fat-saturated T1-weighted gradient echo
(TR = 4.5 TE = 1.9, FA = 12, slice thickness = 4 mm, before interpolation) image during the arterial phase after contrast
administration in this patient is vital for demonstrating the presence of an infiltrative heterogeneous enhancing mass in the upper
pole of the right kidney (arrows). The extension of the mass along the collecting system and the preservation of the renal
morphology suggest the diagnosis of TCC. The liver metastases are again noted. (C) Coronal three-dimensional fat-saturated
T1-weighted gradient echo image (TR = 4.5 TE = 1.9, FA = 12, slice thickness = 4 mm, before interpolation) image during the
delayed phase after administration of gadolinium. The tumor is now less conspicuous because it is near isointense with the renal
parenchyma (arrows). A nodular feature of the tumor is now seen at the wall of the superior calyx, however, after being filled
with contrast (arrowhead). Multiphasic imaging allows for detection and characterization of lesions.
One of the most important applications for con-
trast-enhanced dynamic imaging is three-dimensional
contrast-enhanced MR angiography. Its application
has made MR angiography a widely used modal-
ity for noninvasive evaluation of renovascular dis-
ease. Timing of image acquisition is often performed
by a test bolus [120,121]. Extremely fast acquisi-
tion sequences allow time-resolved contrast-en-
hanced MR angiography for evaluation of renal
artery stenosis without the application of a timing
run [122124].
Technical specifics
Contrast media and volume
Gadopentetate dimeglumine (Magnevist, Berlex
Laboratories, Wayne, NJ) at the dose of 0.1 mmol/kg
is routinely used at the authors institution, although
no efficacy difference among the Food and Drug
Administrationapproved extracellular gadolinium-
chelate contrast agents has been demonstrated. This
dose corresponds to a volume of 0.2 mL/kg. If the
patients weight is unknown, a contrast volume of
20 mL can be used for an adult patient. Another
contrast agent, gadobenate dimeglumine (Multi-
Hance, Bracco, Milan, Italy) is still in the clinical
evaluation phase. It has been shown to produce
higher SNR at when compared with gadopentetate
dimeglumine at the same dose of 0.1 mmol/kg [125];
the possible impact on diagnostic efficacy awaits
further study.
Contrast rate
A contrast rate of 2 mL/second produces excellent
dynamic contrast-enhanced images. A recent report
showed no significant difference in image quality for
renal MR angiography when 0.1 mmol/kg dosing was
compared at rates of 2 and 3 mL/second [126].
Flush volume and rate
A flush with saline of 20 mL at the rate of 2 mL/
second is recommended, although when intravenous
access is established in the hand, the authors recom-
mend using a 30-mL saline flush. The larger volume
is used to maximize the delivery of the contrast dose
to the heart, which ultimately determines the profile
of contrast enhancement in the individuals tissues.
Timing
For dynamic contrast-enhanced imaging, precise
timing of image acquisition during selected periods of
enhancement (eg, renal arterial versus venous phase)
can be accomplished. This precision can be vital both
to lesion detection and characterization (Fig. 14).
Timing of image acquisition is especially important
for efficacious venous-free renal MR angiography.
The use of fixed image delays can suffice in most
patients but is not recommended because it is not
tailored to each patients circulatory dynamics and
results in as high as a 20% failure rate in capturing
the arterial phase [127].
Gradient echo imaging techniques are the corner-
stone for all timing strategies whether this be a test
dose; fluoroscopic monitoring (eg, CAREBOLUS,
Siemens Medical Systems); or automated detection
of the bolus (eg, SMARTPREP, GE Medical Sys-
tems) [128]. A timing bolus of as little as 0.5 to 1 mL
gadolinium can be injected [120,126], but 2 mL
gadolinium is the authors routine. The imaging delay
is determined in each patient on the basis of the
results of the timing examination and has been
described elsewhere [120].
Power injector use
The routine use of MR imagingcompatible
power injectors is recommended to yield reliable and
reproducible contrast delivery for optimized results.
Image processing
For quantitative and semiquantitative image analy-
sis, image postprocessing is often a routine part of
an MR imaging examination. This can be performed
on a workstation and the processed images then
transferred to a picture archiving and communica-
tions system for display or printed out as hardcopies
as needed. To maintain throughput, the image sets
obtained during an MR imaging examination are
transferred to independent workstations and pro-
cessed with commercially available hardware and
software. At the authors institution, this is performed
using the Advantage Windows workstation (GE
Medical Systems) or the Virtuoso workstation (Sie-
mens Medical Solutions).
Subtraction for accurate detection of enhancement
Subtraction of the nonenhanced image set from
the contrast-enhanced data sets is often performed for
better detection of subtle enhancement and to im-
prove the image contrast between vessels and back-
ground tissue. Subtraction is particularly helpful for
detection of a small enhancing component within a
cystic renal lesion (Fig. 15). Each phase from the
dynamic contrast-enhanced MR imaging study is
used as a template from which the unenhanced data
set is subtracted.
Fig. 15. Value of subtracted images for detection of subtle enhancement (same patient as Fig. 11). (A) Sagittal three-dimensional
fat-saturated T1-weighted gradient echo image (TR = 4.5 TE = 1.9, FA= 12, slice thickness = 4 mm, before interpolation) shows
predominantly hyperintense signal intensity within the mass consistent with hemorrhagic products. Note a nodular hypointense
appearance within the anterior aspect of the lesion (arrowheads) and a nodule in the posterior aspect (arrow). (B) Sagittal three-
dimensional fat-saturated T1-weighted gradient echo image (TR = 4.5 TE = 1.9, FA = 12, slice thickness = 4 mm, before
interpolation) at the same level as Fig. 15B after administration of gadolinium. The signal intensity of the hemorrhagic
component of the mass has dropped relatively to the enhanced kidney suggesting lack of enhancement. The anterior
(arrowheads) and posterior (arrow) nodular components of the mass seem to enhance. Subjective assessment, however, of subtle
enhancement in complex lesions can be difficult. (C) Sagittal image obtained after subtraction of precontrast image (Fig. 10B)
from postcontrast image (Fig. 10C). Enhancement of the anterior (arrowheads) and posterior (arrow) nodular component is now
readily seen. The signal intensity of the hemorrhagic component of the lesion appears black because of lack of enhancement.
Subtraction often serves as the first step for further
imaging processing, such as the three-dimensional
reconstructions for MR angiography, including MIP
and VR [52]. Image subtraction improves the quality
of renal MR angiography in terms of both contrast-to-
noise ratio and visualization of the distal renal arteries
[129]. When using subtraction for the qualitative
assessment of renal lesion enhancement, it is impor-
tant to evaluate the degree of misregistration that may
be present. The authors use the thickness of a
ghosting artifact around the renal contour as an index
of the degree of misregistration (Fig. 16).
Three-dimensional reconstruction algorithms for
vascular anatomy and surgical planning
The volumetric data acquired by MR angiography
provide visualization in arbitrary oblique planes of
the renal arteries, allowing evaluation of stenosis
that is unattainable with projection techniques used
Fig. 16. Pseudoenhancement caused by respiratory misregistration. (A) Coronal HASTE image at the level of the kidneys shows
a homogeneously hyperintense lesion in the inferior pole of the right kidney suggesting a simple cyst (arrow). (B) Coronal three-
dimensional fat-saturated T1-weighted gradient echo sequence (TR = 4.5 TE = 1.9, FA = 12, slice thickness = 4 mm, before
interpolation) after administration of gadolinium confirms the presence of a nonenhancing simple cyst in the inferior pole of the
right kidney (arrow). (C) Coronal subtracted image (venous phase, unenhanced) shows a focus of high signal intensity in the
inferior pole of the cyst (arrow). This can be misinterpreted as enhancement. Note the rim of hyperintensity (ghosting artifact)
around the superior pole of both kidneys (arrowheads) related to respiratory misregistration between the precontrast and
postcontrast images. Careful review of source images and, if needed, a quantitative comparison of SI between unenhanced and
enhanced images are important for identifying pseudoenhancement.
in conventional angiography [19]. Because source
images are still subject to partial volume effects
[130], three-dimensional reconstructions have been
performed to enhance diagnostic confidence, to de-
lineate better the vascular anatomy, and to define
better its relationship to adjacent structures [52].
The MIP algorithm is the most widely used post-
processing technique for MR angiography and the
resulting images are readily accepted by referring
physicians. As the first step of reconstruction, the non-
enhanced data set is subtracted from that of the arterial
phase. Targeted MIP images are then obtained in
coronal and transverse projections selected to encom-
pass the renal artery from the origin to the renal hilum.
Volume rendering images also are generally cre-
ated in transverse and coronal orientations to demon-
strate the renal artery from its origin to the renal
hilum. VR has been implemented as a three-dimen-
sional reconstruction technique for postprocessing of
renal CT angiography [131], and its application in the
evaluation of MR angiographic images has also been
investigated. It has been reported that VR algorithm
improves perceptibility and precision in the evalua-
tion of renal arterial lumina when compared with MIP
algorithm [132,133], with a higher specificity and
accuracy especially with regard to detection of mod-
erate and severe stenosis [52,132]; the VR algorithm
also better delineates overlapping vascular structures
[52,134]. Further information regarding the principles
of VR can be obtained elsewhere [131,135,136].
The use of multiplanar reformations affords
unique perspective and can improve diagnostic accu-
racy [137,138]. Other reconstruction techniques, such
as shaded-surface display and virtual intra-arterial
endoscopy, seem to be time-consuming without pro-
viding much useful diagnostic gain [137]. One inter-
esting technical development for processing image
data attempts to quantify the degree of renal artery
stenosis automatically by using a computer system
[139]. This approach has potential to provide rapid and
reproducible results but requires clinical validation.
Both VR and multiplanar reformations have been
used in therapeutic planning for total and partial
nephrectomy surgery. The authors urologists have
found useful a preoperative review that offers multi-
ple surgical perspectives. In essence with interactive
VR and progressive restrictions on the data set
presented, the resultant virtual surgery can reveal
the tissues and structures that are encountered during
a particular surgical approach (Fig. 17)
Summary
This article describes the principles, attributes,
and pitfalls of the many MR imaging approaches
available for assessment of renal-related disorders.
Tables 1 and 2 summarize the specific approach
and rationale.
Fig. 17. Retroaortic renal vein in 59-year-old man with painless hematuria. (A) Coronal subtracted three-dimensional fat-
saturated T1-weighted gradient echo image (venous phase, unenhanced) demonstrates enhancement of a lesion at the lower pole
of the left kidney (arrow). (B) Coronal volume-rendered image obtained from the same postcontrast phase as in Fig. 17A. There
are two renal arteries for the left kidney (arrowheads) and a retroaortic renal vein (arrow) is readily noted. Information about the
vascular anatomy is important before nephrectomy, particularly when laparoscopic approach is to be attempted.
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Evaluation of renal causes of hypertension
Robert P. Hartman, MD
*
, Akira Kawashima, PhD, MD, Bernard F. King, Jr, MD
Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester MN 55905, USA
Hypertension currently affects approximately
60 million Americans and can lead to significant
morbidity and mortality including heart disease and
renal failure. Although most people suffer from essen-
tial hypertension, a substantial subset (5% to 10%) has
a secondary cause. Of this group of secondary causes,
renal parenchymal disease and renovascular disease
are the most prevalent. Specific causes are as follows:
Renovascular disease
Atherosclerosis
Fibromuscular dysplasia
Renal artery aneurysm
Arterial artery dissection
Vasculitis (polyarteritis nodosa)
Takayasus arteritis
Neurofibromatosis
Mid-aortic syndrome
Arteriovenous communications
Posttraumatic hypertension
Renal parenchyma disease
Nephropathy (diabetic nephropathy, glomeru-
lonephritis, lupus nephritis, nephrosclerosis)
Chronic pyelonephritis
Tumors (juxtaglomerular cell tumor)
Polycystic kidney disease (autosomal dominant
and recessive)
Page kidney (chronic subcapsular hematoma
and perirenal fibrosis)
Other nonrenal secondary causes of hypertension
include primary aldosteronism, Cushings disease,
pheochromocytoma, coarctation of the aorta, hyper-
calcemia, carcinoid syndrome, central nervous system
tumors, and acromegaly. This article concentrates on
the renal-mediated secondary causes of hypertension.
Renovascular disease
Renal artery stenosis
Renal artery stenosis (RAS) accounts for most
renal-mediated hypertension, likely accounting for
1%to 5%of all cases of hypertension in the population
[1]. The benefits of revascularization (either surgically
or angiographically) are generally accepted as a better
form of long-term therapy in these patients [2].
Although affecting a smaller group of people, the
diagnosis of hypertension secondary to RAS is impor-
tant, because it is often a correctable cause of disease.
If treated, the blood pressure can be lowered or cured
and the kidneys and other end organs can be protected.
Renovascular hypertension is a renin-dependent
elevation of blood pressure resulting from renal
ischemia and decreased renal profusion caused by a
stenotic lesion of the renal artery or its segmental
branches. This results in decreased perfusion of the
glomerulus. This decreased glomerular blood flow in
the afferent arteriole is detected by baroreceptors in
the juxtaglomerular apparatus. This results in renin
release into the bloodstream. In addition, decreased
sodium load in the renal tubules, as a result of renal
artery stenosis, is detected by the macula densa,
which in turn causes further renin release by the
juxtaglomerular apparatus. Increased renin levels re-
sult in the production of angiotensin II, which then
goes on to cause vasoconstriction of blood vessels
and an increase in the production of aldosterone.
Aldosterone can then go on to produce vasoconstric-
doi:10.1016/S0033-8389(03)00071-X
E-mail address: Hartman.Robert@mayo.edu
(R.P. Hartman).
Radiol Clin N Am 41 (2003) 909929
tion of the blood vessels and also results in sodium
and water retention (Fig. 1).
Renal vascular hypertension from RAS has a low
prevalence within the general public. Screening of all
patients with hypertension for RAS is not warranted.
Careful clinical screening of patients for particular
findings or medical histories, however, allows for the
identification of patients at higher risk of RAS [3].
Clinical findings associated with renal artery stenosis
include the following:
Hypertension
Abrupt onset of hypertension before the age of
30 years (suggestive of fibromuscular
dysplasia)
Abrupt onset of hypertension at or after the age
of 50 years (suggestive of atherosclerotic
RAS)
Accelerated or malignant hypertension
Refractory hypertension (not responsive to
therapy with three drugs)
Renal abnormalities
Unexplained azotemia (suggestive of athero
sclerotic RAS)
Azotemia induced by treatment with an
angiotensin converting enzyme inhibitor
Unilateral small kidney
Unexplained hypokalemia
Other findings
Abnormal bruit, flank bruit, or both
Severe retinopathy
Carotid, coronary, or peripheral vascular
disease
Unexplained congestive heart failure or acute
pulmonary edema
In particular, the onset of hypertension before the
age of 30 or after the age of 50, worsening hyperten-
Fig. 1. Pathophysiology of renovascular hypertension. (From the Mayo Foundation; with permission.)
R.P. Hartman et al / Radiol Clin N Am 41 (2003) 909929 910
sion despite multiple therapies, associated peripheral
vascular disease, cigarette smoking, an abdominal
bruit, or concomitant renal dysfunction in the setting
of hypertension are possible signs of atherosclerotic
RAS. The suspicion for fibromuscular dysplasia
(FMD) increases in hypertensive women under the
age of 30 or younger patients with an abdominal
bruit. Using these particular clinical findings a subset
of patients with hypertension can be selected where
the prevalence of RAS in the group can be as high as
47% [4]. These patients can then be screened appro-
priately with diagnostic imaging.
It is important to note that not all RAS infers
renal vascular hypertension. The diagnosis of renal
vascular hypertension is reserved for patients with
renin-mediated hypertension who benefit from
revascularization of the affected kidney or kidneys.
In some patients RAS may be present but they do not
receive any benefit from revascularization, and some
patients with essential hypertension have RAS that is
not hemodynamically significant.
For these reasons the diagnostic evaluation of
patients with suspected RAS can be challenging. Many
imaging modalities have the ability to detect anatomic
stenoses of the renal arteries including catheter-di-
rected digital subtraction angiography, CT angiog-
raphy, color-flow Doppler ultrasonography, and MR
angiography. Angiotensin converting enzyme (ACE)
inhibition renal scintigraphy images the functional
changes associated with RAS rather than the anatomic
lesion. MR angiography and Doppler sonography can
also measure functional changes. Serumand renal vein
renin measurements have also been advocated in the
evaluation of renovascular hypertension.
Renal artery stenosis is the leading cause of renal
vascular hypertension. The two most prevalent causes
of RAS in the population are atherosclerotic disease
and FMD. Other diseases, such as neurofibromatosis,
vasculitis, renal artery dissection, aortic aneurysm, or
mid-aortic syndrome, account for a small percentage
of RAS.
Atherosclerotic disease
Atherosclerotic disease is a progressive degenera-
tive disease that affects older patients. It is the most
common disease causing RAS, accounting for ap-
proximately 70% to 80% of cases [5]. The disease
usually affects the entire circulatory system and can
cause other symptoms, such as angina, transient
ischemic attacks, claudication, or mesenteric ische-
mia. The lesions usually involve the origin or proxi-
mal portion of the renal artery. Risk factors for the
development of atherosclerosis include diet, high
cholesterol, smoking, and genetic predisposition [6].
Renal artery stenosis secondary to atherosclerotic
disease may be caused by a primary lesion within the
renal artery or from secondary extension of plaque
from the abdominal aorta. Primary lesions are caused
by eccentrically located atheromatous plaques that
usually affect the proximal third of the renal artery
(Fig. 2). Ostial lesions caused by exuberant plaque
within the aorta are difficult to differentiate from
renal artery plaques but have important implications
for therapy.
The plaques reside beneath the intima and are a
mixture of cholesterol or cholesterol esters and fi-
brous tissue with or without calcification. The fibrous
tissue is comprised of smooth muscle cells, collagen,
elastin, and proteoglycans. The plaque can enlarge or
coalesce leading to luminal narrowing. This leads to
activation of the renin-angiotensin II pathway and
higher systemic blood pressures.
Atherosclerosis is a progressive disease and can
lead to renal insufficiency or failure. Occlusion of the
renal artery also has been reported in up to 14% of
cases [7].
Fibromuscular dysplasia is the second most com-
mon cause of RAS, accounting for approximately
15% to 20% of all cases. There are four major types
of FMD. In adults the most common form is medial
fibroplasia. The other forms are perimedial fibro-
plasia, intimal fibroplasia, and medial hyperplasia
Fig. 2. Atherosclerotic renal artery stenosis. Digital sub-
traction abdominal aortogram demonstrates a high-grade
stenosis of the proximal left renal artery (arrow).
[8]. Adventitial or periarterial fibroplasia can also
result in RAS.
Medial fibroplasia accounts for about 70% of all
cases of FMD. It occurs most often in women between
the ages of 25 and 50 years and is rare in children. It
tends to affect the distal two thirds of the main renal
artery and its major branches. Other vessels in the
body, such as the carotid and vertebral arteries and the
mesenteric and iliac arteries, also can be involved.
Histologically the internal elastic membrane is lost
or thinned and collagen bands replace the muscle.
These bands within the renal artery lead to focal areas
of narrowing that can be accompanied by regions of
poststenotic dilatation with a resulting classical ap-
pearance of the string of beads (Fig. 3) [8].
Perimedial fibroplasia occurs in women between
the ages of 15 and 30 years. It comprises about 15%
to 20% of all cases. A tight stenosis of the renal artery
occurs secondary to deposition of collagen in the
outer border of the media.
Intimal fibroplasia is a rare condition that affects
children and young adults (often male), accounting for
2% to 5% of all cases. It results in a focal narrowing of
the renal artery or segmental arteries because of
Fig. 3. (A) Digital subtraction, catheter-directed angiogram of the abdominal aorta and branches demonstrates alternating areas
of stenosis with a beaded appearance in the main right renal artery (arrow). The changes are characteristic to fibromuscular
dysplasia. Maximum intensity projection (MIP) contrast-enhanced MR angiogram (B), three-dimensional volume rendering (VR)
CT angiogram (C), and catheter-directed selective digital subtraction angiogram (D) of the same patient.
circumferential collagen deposition in the internal
elastic lamina. Medial hyperplasia is also rare, result-
ing from diffuse proliferation of smooth muscle.
Adventitial or periarterial fibroplasia causes 1% of
cases of FMD. Focal or tubular stenoses result from
dense fibrous tissue surrounding the renal artery.
Imaging of RAS secondary to atherosclerotic disease
and FMD
The imaging of RAS caused by atherosclerosis or
FMD is similar. The following sections are descrip-
tions of the many imaging modalities that are avail-
able to the radiologist when a patient is referred with
the possibility of RAS from either of these etiologies.
Functional versus anatomic imaging
The choice of modality used as the initial tool for
the evaluation of RAS varies within institutions based
on availability and physician expertise. In addition, the
clinical suspicion for RAS plays a role. In a patient
with a very lowsuspicion of RAS, imaging of the renal
vasculature should not be pursued. In contrast, given a
high level of suspicion for RAS, catheter-directed
contrast angiography is a legitimate choice because
therapeutic measures can be provided at the time of the
study. The group of patients with an intermediate level
of suspicion for RAS is those that are often referred for
noninvasive screening examinations.
Some modalities offer direct identification of a
lesion resulting in RAS, whereas others identify
functional changes in the kidney. The modalities
capable of detecting anatomic lesions include digital
subtraction angiography, color-flow Doppler ultra-
sonography, CT angiography, and MR angiography.
The only modality in widespread use for the detection
of changes in renal function secondary to RAS is
ACE-inhibition renal scintigraphy, although ACE-
inhibition dynamic gadolinium MR imaging is under
investigation [9,10].
ACE-inhibition renal scintigraphy
Angiotensin converting enzyme inhibition renal
scintigraphy images the kidneys with tubular agents,
such as Tc 99m mercaptoacetyltriglycine and I 131
o-iodohippurate sodium, or glomerulofiltration agents,
such as Tc 99m diethylenetriamine pentaacetic acid
(DTPA). Currently, Tc 99m mercaptoacetyltriglycine
(MAG3) is the most commonly used agent. The scan
is performed as an outpatient examination after the
patients use of ACE inhibitors (ie, captopril) has
been discontinued.
In a patient with unilateral RAS, the affected
kidney increases the output of renin, which through
the renin-angiotensin pathway leads to increased
levels of circulating angiotensin II. Angiotensin II
affects the kidneys by constricting the efferent arte-
riole resulting in higher pressures within the glo-
meruli. When an ACE inhibitor is introduced the
conversion of angiotensin I to angiotensin II is
limited, lowering circulating levels and diminishing
the result on the efferent arteriole (Fig. 4). This in
turn decreases the perfusion pressure within the
glomerulus with resultant drop in the glomerular
filtration rate [11]. The filtration of the circulating
isotope is decreased (Tc 99m diethylenetriamine
pentaacetic acid) and urine flow drops leading to
delayed transit time of tubular secretion agents
(I 131 o-iodohippurate sodium, Tc 99m mercapto-
acetyltriglycine) (Fig. 5).
Different institutions use varying protocols for
ACE-inhibition scintigraphy. In all cases, patients
have to discontinue ACE-inhibitor medication being
used to treat their hypertension. Although it is ideal to
withhold all ACE-inhibition medication for 48 hours,
most institutions withhold ACE inhibitors for only
24 hours. Some institutions obtain a baseline scan
followed by a scan with ACE inhibition either later
that day or on a following day. The 1-day protocol is as
follows. A baseline blood pressure is obtained and the
patient is hydrated to ensure adequate urine flow
during the examination. The initial scan is performed
and uptake and excretion curves are obtained. The
initial dose is allowed to clear and after a number of
hours a second blood pressure is obtained and
recorded. An ACE inhibitor is administered and serial
blood pressures are obtained every 15 minutes for 60 to
90 minutes while the patient receives intravenous
fluids. A second dose of radiopharmaceutical is then
administered and the patient is scanned again, obtain-
ing the appropriate uptake and excretion curves
as before.
An alternative method for the examination is a
single scan after the administration of an ACE inhibi-
tor; however, this demonstrates a lower sensitivity and
specificity than the combined pre and post ACE-
inhibition studies. This relies on the delayed elimina-
tion of isotope from the kidney to diagnose RAS,
rather than the change in the elimination of isotope
frombaseline to post ACE-inhibitor scans. If the scan
is normal, only one dose of radiopharmaceutical needs
to be administered and this cuts down on examination
times. If equivocal findings are present on the single
scan, a baseline examination can then be performed
after an appropriate interval to allow for the ACE-
inhibition to wear off.
The ACE-inhibition scintigraphy has a reported
sensitivity of 80% and specificity of near 100% for
the detection of RAS [12]. ACE-inhibition scintig-
raphy provides a functional rather than anatomic
diagnosis and is recommended when an intermediate
clinical suspicion exists or there is a desire to deter-
mine whether a known RAS is functionally signifi-
cant. In addition, there is good correlation between
the findings on renal scintigraphy and results of
treatment. Pretherapy scans act as good baseline
examinations, and residual or restenosis of the artery
can be detected after intervention has occurred.
The ability to detect disease with renal scintig-
raphy is limited in patients with renal insufficiency,
which is prevalent within older patient populations
with atherosclerosis, and in patients with bilateral
disease. Most often in bilateral disease there is an
asymmetry of disease that can be detected; however,
occasionally bilateral symmetric disease can be
missed. For these reasons it is most beneficial to
acquire pre and post ACE-inhibition studies.
A positive scan is sufficient evidence to proceed
to angiography and intervention if a lesion is iden-
tified. Predicted improvement in blood pressure after
intervention in these patients has a reported accuracy
of 90% to 98% [13].
Doppler ultrasonography
Since the introduction of duplex Doppler color-
flow ultrasound the usefulness of ultrasound for the
detection of RAS has improved. Ultrasound is a less
expensive noninvasive test that can be performed on
patients without necessitating the discontinuation of
their antihypertensive medications. The usefulness of
ultrasound remains limited, however, secondary to
operator-dependent issues; technical failure (body
habitus, bowel gas); and inability to image small
accessory arteries. Despite these limitations, ultra-
sound has become a leading modality in screening
for RAS.
Fig. 4. Physiologic effects of renal artery stenosis and angiotensin converting enzyme inhibitor (ie, captopril) on glomerular
filtration. (From the Mayo Foundation; with permission.)
Fig. 5. Unilateral renal artery stenosis. (A) Tc 99m MAG3 angiotensin converting enzyme inhibition (captopril) renogram images
from 1 minute through 20 minutes, including postvoid image, demonstrates delayed progression of tracer activity in the left
kidney with delayed cortical uptake (short arrow) and excretion (long arrow), characteristic of left renal artery stenosis.
(B) Cortical perfusion curve demonstrates the quantitative measure of the delayed tracer activity in the left kidney relative to the
aorta and the right kidney. (C) Excretion curve demonstrates the quantitative measure of the prolonged tracer activity in the left
kidney relative to the right kidney.
The detection of RAS with ultrasound requires a
complete examination of the kidneys including gray-
scale images of the kidney size and contour and color
Doppler and spectral tracings of the vessels. The
examination of the renal vasculature includes images
of the main renal artery and intrarenal segmental
arteries. Detection of RAS when evaluating the main
renal arteries depends on an increased peak systolic
velocity of blood flow through the stenotic segment
and changes seen in the caliber of the color flow
through the artery and Doppler aliasing. As the
stenosis progresses, the cross-sectional diameter of
the lumen decreases. This in turn leads to an increase
in the velocity of blood traversing the segment.
The upper limit of peak systolic velocity that indi-
cates a significant stenosis varies in the literature.
Currently, a peak systolic velocity greater than 180 to
200 cm/second is commonly accepted as this limit
(Fig. 6A) [14,15]. Additionally, a relative velocity
ratio comparing the aorta with the renal artery has
been used. In this instance a renoaortic peak systolic
velocity ratio of greater than 3.5 is indicative of a
hemodynamically significant stenosis [16]. In addi-
tion to velocity change, a focal stenosis often causes
turbulent flow within the artery that can be identified
as aliasing on the color Doppler images.
To use these criteria it is necessary to image the
entire length of the main renal arteries. This unfortu-
nately is not as easy as it might seem. Technical
failure to image the renal artery along its length
commonly occurs in obese patients and patients with
a large amount of bowel gas. The technical failure
rates range from 4% to 42% in the literature [17]. The
examination is operator-dependent, and failure rates
are lower at institutions that perform larger numbers
of these examinations. In addition to nonvisualization
of the main renal arteries, 14% to 24% of patients
have accessory renal arteries that often are undetected
by ultrasound [18]. In the authors practice, this
technique has a sensitivity and specificity of 85%;
however, the limitations of technical failures and
nonvisualized accessory arteries are significant.
An additional method of sonographic evaluation
for RAS focuses on changes in the segmental renal
arteries downstream from the stenosis. Although the
visualization of the main renal arteries is variable, the
segmental arteries within the kidneys are usually easy
to routinely identify and interrogate. These arteries
are too distant from the stenosis to exhibit increased
velocities but rather have dampened velocity wave-
forms. Specifically, the segmental arteries can exhibit
a tardus (late)-parvus (small) waveform in patients
with a more proximal RAS.
The normal velocity waveform within a segmental
artery has a rapid systolic upstroke with an early
systolic peak. The velocity waveform of all renal
arterial vessels is a low-resistance waveform with
forward flow in diastole. Quantitatively, the segmen-
tal arteries can be evaluated with several different
parameters: the acceleration time, acceleration index,
and the resistive index. The acceleration time is the
time from the start of systole to peak systole, and is
normally less than 70 milliseconds. The acceleration
index is the slope of the systolic upstroke and is
normally at least 3.5 m/second [19]. The resistive
index is a ratio of the systolic and diastolic velocities
within the segmental arteries. It is calculated with the
use of the following equation: [1-(end-diastolic ve-
locity/ maximal systolic velocity)]. A normal value
for the resistive index is usually less than 0.7 [17].
Fig. 6. Renal artery stenosis. (A) Duplex ultrasonogram of the main right renal artery demonstrates elevated peak systolic
velocities (5.53 m/second, normal < 1.8 m/second) consistent with a high-grade stenosis. (B) Duplex ultrasonogram of the
segmental renal artery in the upper pole of the right kidney in the same patient demonstrates a tardus-parvus waveform distal to
the main renal artery stenosis. Note the acceleration time (dT) is prolonged (179 milliseconds, normal < 70 milliseconds) and the
acceleration index is lower (2.36 m/second, normal > 3.5 m/second).
In contrast, the segmental arteries downstream
from a hemodynamically significant RAS have a
delayed systolic upstroke with decreased overall flow.
This is the aforementioned tardus-parvus waveform.
Acceleration time is longer while the acceleration
index is lower than normal secondary to the delayed
systolic peak. The resistive index is greater because
of lower amplitude of the systolic peak (Fig. 6B).
This method by itself also has been shown to have
sensitivity and specificity greater than 80% for the
detection of RAS, whereas not having as high a
degree of technical failure [19].
Recent studies using a combined approach of
imaging both the main renal arteries and the segmental
renal arteries have reported a technical failure rate of
0% with 96% sensitivity and 98% specificity com-
pared with angiography [17]. This combined approach
is likely the best way of evaluating for RAS with
Doppler ultrasound presently. In the future ultrasound
examinations following ACE inhibition to enhance the
tardus-parvus waveform, use of echocontrast media,
and future generations of sonographic machines may
increase the usefulness of ultrasonography as a screen-
ing modality beyond where it is now.
Besides imaging the anatomic stenosis attempts
have been made using sonographic criteria to deter-
mine which patients with RAS benefit from revascu-
larization. A recent study suggests that renal function
and blood pressure did not improve in patients with a
resistive index greater than 0.80 in an effected kidney
despite revascularization [20]. This is possibly be-
cause of changes within the renal parenchyma and
vessels, such as glomerulosclerosis or nephrosclero-
sis, from long-standing hypertension. Further studies
regarding this are necessary.
MR angiography
MR angiography has made significant progress in
its use as a screening examination for RAS in the past
few years in part because of improvements in gradient
systems, the advent of breathhold imaging sequences,
and centric k-space phase encoding. The examination
continues to have limitations because of lack of
widespread availability of capable MR imaging scan-
ners; costs; and patient issues, such as claustrophobia.
In the past phase contrast and time-of-flight MR
angiography of the renal arteries was used for the
detection of RAS. The diagnosis was based on
imaging the anatomic narrowing in the vessel (time-
of-flight and phase contrast) and signal loss caused by
dephasing of the blood from turbulent flow in the
poststenotic renal artery (phase contrast). Dephasing
of blood within a given artery on phase-contrast MR
angiography has been shown in the past to have a
correlation with significant stenoses [21]. These
examinations, however, took many minutes to per-
form with image quality suffering from respiratory
motion. Overgrading of stenoses caused by the
dephasing artifact also occurred. In addition, only
the proximal renal arteries could be imaged, which
often excluded identification of stenoses caused by
FMD, which tend to be more peripheral.
In the past few years gadolinium-enhanced three-
dimensional spoiled gradient echo imaging during a
single breathhold has become more widely used. The
images do not suffer from respiratory motion degra-
dation, and the three-dimensional image data set
allows for viewing of the renal arteries in an infinite
number of projections. Gadolinium bolus timing and
the advent of elliptical centric k-space sampling have
allowed for the imaging of the renal arteries at peak
arterial enhancement during the first pass while
limiting venous contamination of the image and
further reducing the effects of respiratory motion
(Fig. 7) [22].
Finally, smaller fields of view are being used to
increase the spatial resolution of the images allowing
for better grading of the degree of stenosis and aiding
in the detection of peripheral stenoses and the visual-
ization of accessory renal arteries. This has been
shown to have a sensitivity of 97% and specificity
of 92% compared with intra-arterial angiography for
the detection of RAS including distal main and
segmental arteries [23]. Within the study group all
Fig. 7. Atherosclerotic renal artery stenosis. Gadolinium-en-
hanced, MR angiogram of the abdominal aorta and renal
arteries demonstrates bilateral, proximal renal artery stenoses
(arrows) caused by atherosclerotic renal artery disease.
segmental artery stenoses and middle to distal main
artery stenosis caused by FMD were depicted [23].
MR angiography is continuing to improve in the
detection of RAS. In addition to anatomic depiction
of stenoses the possibility of using dynamic gado-
linium images of the kidneys to detect functional
changes similar to those evaluated by ACE-inhibited
scintigraphy may be possible [9,10]. Ultimately, this
may provide similar predictive value regarding the
likelihood of improvement in renal function and
blood pressure in patients with diagnosed RAS. This
would allow for a better selection of patients to
undergo revascularization of the kidney.
CT angiography
With the advent of slip ring, single-detector heli-
cal CT scanners it became possible to perform 40
contiguous 1-second tube rotations within a single
breathhold. This combined with continuous table
motion during the examination allowed for the
acquisition of volumetric imaging data from the
abdominal aorta and its major branches. Recent
availability of multidetector helical CT scanners has
increased the spatial resolution of these studies,
which was already greater than the spatial resolution
of MR angiography [24]. Image sets are recon-
structed to submillimeter slice thickness during
reprocessing. The image data then can be viewed
on a capable workstation in an infinite number of
projections given the three-dimensional acquisition.
Different three-dimensional rendering techniques, in-
cluding maximum intensity projection and volume
rendering, have been studied in recent years for their
individual ability to detect RAS [25].
Maximum intensity projection algorithms produce
images by establishing the maximum voxel intensity
along a ray within the data set. This allows for
differentiation between intra-arterial contrast and ec-
centric calcified plaque along the arterial wall, and
different attenuations within the kidneys themselves.
Some of the three-dimensional relationships, how-
ever, can be lost. When viewing maximum intensity
projection images it is important to view the original
data set in multiple projections to ensure that plaque
is seen adjacent to, rather than overlying, the lumen.
This helps decrease the overestimation of stenosis
Fig. 8. Noncalcified atherosclerotic renal artery stenosis. Three-dimensional maximum intensity projection (A) and volume
rendering (B) CT angiograms demonstrate a focal noncalcified stenosis in the main left renal artery (arrows). Note the
poststenotic dilatation of the renal artery.
severity. The sensitivity of maximum intensity pro-
jection images is approximately 94% with a speci-
ficity of 87% (Fig. 8) [25].
Volume rendering is an interactive three-dimen-
sional-rendering algorithm that computes a volumetric
image that contains all attenuation values. To view the
renal vessels, however, the display must be manipu-
lated to remove obscuring structures. To do this
subjective optimization of the display is required
including window width, level, and brightness. As in
maximum intensity projection images the image data
can be viewed in multiple projections and calcified
plaque in the artery is easily distinguished from
luminal contrast. Volume rendering is better than
maximum intensity projection images in maintaining
the three-dimensional vascular relationships. The sen-
sitivity of volume rendering for the detection of RAS is
similar to maximum intensity projection, whereas the
specificity is better, approximately 99% (Fig. 9) [25].
Accessory arteries to the kidneys can arise any-
where along the aortoiliac course from T11 to L4.
Ninety percent of these, however, occur within 17 mm
cephalad to the main renal artery and 70 mm caudal.
For this reason, images should be prescribed to
include as much of the abdominal aorta as possible.
CT angiography is a good test for detecting accessory
arteries when they are present.
The limitations of CT angiography include the use
of iodinated contrast material and ionizing radiation.
A substantial number of patients with suspected RAS
have renal insufficiency, a relative contraindication to
the use of iodinated contrast media. In addition, there
is the possibility of allergic reactions when adminis-
tering iodinated contrast media. For these reasons, CT
angiography may not be the best first choice as a
screening test for RAS.
Intra-arterial angiography
Catheter-directed intra-arterial angiography re-
mains the gold standard for the detection of RAS. It
is most commonly performed using a Seldinger tech-
nique to gain access to a femoral artery. Using a small
catheter (4 to 5F catheter) iodinated contrast, CO
2
, or
gadoliniumchelate is injected into the abdominal aorta
at the level of the renal arteries. Multiple projections
should be obtained to ensure complete visualization of
the entire course of the main renal arteries. This helps
limit the chance of overlooking a short ostial stenosis.
Grading of the stenosis is done by comparing the
luminal diameter at the stenosis with the diameter of
the normal-caliber renal artery adjacent to the stenosis.
Digital subtraction angiography also can be performed
in a similar manner. This can allow for the use of
smaller amounts of contrast material.
The greatest advantage of catheter-directed angi-
ography over the previously discussed modalities is
the ability to intervene and correct the stenosis if
identified. The treatment options for revascularization
are discussed later. Disadvantages include the use of
iodinated contrast media and its inherent risks of
allergic reaction and relative contraindication in
patients with renal insufficiency. In addition, the
procedure is invasive and caries a reported mortality
rate of 0% to 2%. Other complications, although rare,
include contrast-induced renal failure, atheroemboli,
pseudoaneurysm, and hematoma. Currently, only
patients with a high suspicion of RAS should proceed
to intra-arterial angiography as the first diagnostic
tool given the potential complications.
Treatment of RAS
The treatment options in patients with RAS
caused by atherosclerosis or FMD are generally
percutaneous intervention versus surgery for revas-
cularization of the kidney. The patients health status,
and etiology and severity of the RAS, including
vascular disease in the abdominal aorta and mesen-
teric arteries, must be considered in determining the
proper intervention. In general, percutaneous trans-
luminal renal artery angioplasty (PTRA), with or
without stenting, has become a commonly accepted
initial therapy.
Percutaneous transluminal renal artery angioplasty
Since its introduction in 1978, PTRA has gained
steady acceptance and has produced increasingly
positive results. This is because of advancements in
soft and hydrophilic-coated wires, and catheter and
balloon designs. The procedure consists of identify-
ing the stenotic segment in the renal artery with an
injection of contrast material, traversing the segment
with a soft guidewire, positioning an expandable
balloon across the segment, and inflating the balloon
to expand the diameter of the segment. In atheroscle-
rotic disease the mechanism of therapy consists of
fracturing of the atheroma, tearing of the intima and
media, and dilatation of the adventitia. In contrast,
PTRA of FMD results in fracturing of the bands or
webs that cause the focal luminal stenosis.
Percutaneous transluminal renal artery angioplasty
is now the accepted therapy for patients with FMD.
This is caused in part by the fact that FMD is not a
systemic disease and when successfully treated the
lesions do not tend to recur. The technical success
rate for PTRA in treating FMD is about 90% with a
therapeutic benefit in 70% to 90% of patients [26,27].
Patients with FMD tend to be younger and have
Fig. 9. Atherosclerotic renal artery stenosis. Maximum intensity projection (A) and volume rendering (B) three-dimensional
CT angiograms demonstrate a calcified atherosclerotic plaque in the main right renal artery (short arrow) and a noncalcified
stenosis in the main left renal artery (long arrow). (C) Axial reformat image showing the eccentric plaque in the proximal right
renal artery. (D) Digital subtraction abdominal angiogram demonstrates the focal stenosis in the left main renal artery
corresponding to the CT angiographic findings (arrow). The right renal artery appears normal.
fewer comorbid conditions than those with athero-
sclerotic disease, and this helps limit the number of
complications. The complication rate ranges from 2%
to 10% and includes dissection, thrombosis, and rup-
ture of the renal artery.
Atherosclerotic vascular disease accounts for most
RAS, likely 70% to 80% of all cases [5]. Atheroma-
tous plaques filling a portion of the native renal artery
lumen cause the stenosis. It is a degenerative disease
and effects older patients. In addition, it is not limited
to the renal circulation and tends to progress and
recur. Because of these factors the technical success
rate for PTRA is lower in this group of patients
relative to those with FMD. The technical success
rate generally reported is 80% [28].
The success rate of PTRA can be evaluated in a
number of ways. The most commonly studied is
clinical benefit following PTRA. Approximately 70%
to 80% of patients with unilateral atherosclerotic renal
artery stenosis can expect beneficial results in blood
pressure control following PTRA [2]. Other modes of
evaluation include primary and secondary patency
rates, but these have not been extensively studied.
The complication rate of PTRA in atherosclerotic
disease is higher than in FMD. These range from 10%
to 13% and include renal artery thrombosis, dissec-
tion or rupture, embolization, myocardial and cere-
bral infarction, renal insufficiency, pseudoaneurysm,
and hematomas. The mortality of the procedure is up
to 4% [2].
A subset of RAS caused by atherosclerotic vas-
cular disease is ostial lesions. Previously these were
believed to be refractory to PTRA. It was the opinion
of many that dilating the aortic wall in addition to the
plaque is more difficult and the risk of dislodging
plaque within the aorta is greater. Despite this a 58%
clinical benefit was recently reported following
PTRA (without stents) of ostial lesions [29].
The use of expandable metallic stents in treating
RAS is currently under investigation. The stents may
help in the treatment of complicated or recurrent
stenoses, including ostial lesions. Recent reports have
shown a 96% technical success rate and a 64%
clinical benefit in patients with ostial lesions treated
with angioplasty and a stent [30].
The success of PTRA versus surgical intervention
has only had limited study. In one report the primary
patency, secondary patency, and clinical benefit of
patients with unilateral atherosclerotic RAS were
similar between PTRA and surgery. The complica-
tions following PTRA (17%), however, were con-
siderably lower than following surgery (31%) [2].
PTRA continues to be a safe and effective procedure
for the treatment of RAS.
Surgery
Surgical correction of RAS includes aortorenal or
alternative arterial bypass procedures, unilateral ne-
phrectomy, endarterectomy, and atherectomy. Bypass
procedures are the most common type of surgical
treatment. The technical success rate for surgical
intervention is high with a restenosis rate usually less
than 10% [31]. In patients with atherosclerotic vas-
cular disease affecting the abdominal aorta and caus-
ing RAS, a surgical procedure including simultaneous
replacement of the aorta and revascularization of the
kidney may be the best alternative. The rates of cure
or improvement in blood pressure following surgical
revascularization are excellent. Clinical benefit has
been reported in 60% to 90% [31,32]. In addition, the
benefit to renal function is observed in more than
80% with improved function in 35% to 65% [7].
Surgery does carry an increased risk of morbidity
and mortality relative to percutaneous procedures. As
previously mentioned, the complication rate can be
31%. Mortality rates range from 3% to 20% [5].
Takayasus arteritis
Takayasus arteritis is a rare disease that affects
the aorta and main branches. It is divided into a
number of types according to the region of the aorta
and branch vessels affected. When the renal arteries
are affected, hypertension can be a result because the
disease process causes arterial wall thickening and
resultant narrowing of the arterial lumen. The histo-
logic changes in the arterial wall are caused by
transmural disorganization and fibroplasia.
CT and MR imaging of the aorta and renal arteries
including angiographic sequences can demonstrate
the wall thickening in addition to the resultant lumi-
nal narrowing (Fig. 10). Intra-arterial angiography
continues to be used in cases of suspected Takayasus
arteritis, because therapy can be attempted at the time
of the diagnostic procedure.
Treatment of Takayasus arteritis with percuta-
neous dilatation has met with mixed results. Initial
technical success rates can be as high as 95% but
patients often ultimately require surgical interven-
tion [33].
Neurofibromatosis
Neurofibromatosis is a group of diseases that are
hereditary disorders of ectodermal origin. A number
of types of neurofibromatosis have been described.
Von Recklinghausens disease, or neurofibromatosis
type 1, is an autosomal-dominant disease that can
affect the renal arteries. Hypertension in neurofibro-
matosis is often caused by an associated pheochro-
mocytoma. In patients under the age of 18, however,
renal vascular-mediated hypertension is seven times
more likely than pheochromocytoma [3436].
Vascular neurofibromatosis can result in hyperten-
sion caused by an aortic coarctation, extrinsic com-
pression of the renal arteries, or lesions intrinsic to the
renal arteries. Neurofibromatosis has distinct effects
on both the large vessels and smaller branches. Large
vessels are commonly surrounded by neurofibroma-
tous or ganglioneuromatous tissue. In addition,
disorganized growth of the media and intimal pro-
liferation occurs. In the smaller vessels a vasculitis
consisting of intimal thickening, disorganized smooth
muscle growth, and elastic tissue growth may be
present. These changes can result in areas of stenosis,
aneurysms, and occasionally dissection of the renal
arteries. True external compression from local neuro-
fibromas is rare. In neurofibromatosis, stenosis of the
main renal artery is often associated with stenosis of
the intrarenal branches.
CT or MR imaging of the abdomen including
angiographic series is likely the best option for
radiologic evaluation. This allows for the detection
of aortic coarctation or RAS, whether it is caused by
extrinsic compression or intra-arterial disease.
Treatment options for patients with neurofibro-
matosis 1 and renal vascular hypertension include
PTRA, which has been shown to have good initial
results and benefits. Previous studies, however, have
suggested a restenosis rate ranging between 15% and
60% [37]. Surgical intervention with renal artery
bypass is also an option. In both cases, the intrarenal
arterial disease can preclude permanent alleviation of
the hypertension and medical therapy may be neces-
sary for long-term blood pressure control.
Midaortic syndrome
Midaortic syndrome is an entity caused by a
nonspecific arteritis affecting the abdominal aorta
and occasionally the major branches. It is often
present at birth and may progress causing sympto-
matic changes in young adults. The disease can occur
either from hypoplasia of the abdominal aorta with
tubular stenosis of the renal arteries or from true
coarctation of the aorta [38].
The histologic lesion may be severe intimal fibro-
plasia or a transmural aortitis involving the adventitia
and resulting in thickening of the entire wall of the
aorta. Consequently, CTor MR imaging can be useful
modalities in the detection of the disease. As in
Takayasus arteritis the images can detect the wall
thickening, and the angiographic portion of the
examination can depict the luminal narrowing. It
may be difficult to distinguish the imaging findings
of midaortic syndrome from Takayasus aortitis
and neurofibromatosis.
The treatment of midaortic syndrome is usually
surgical, because percutaneous results have been
poor [38].
Renal artery aneurysm and dissection
Renal artery aneurysms can occur from a num-
ber of causes. They can be congenital, mycotic,
traumatic, atherosclerotic, or vasculitic. The most
Fig. 10. Renal artery stenosis in Takayasus arteritis. (A, B) Axial CT images at the level of the renal arteries performed with
contrast demonstrate circumferential wall thickening involving the abdominal aorta (long arrow) and the proximal renal arteries.
Note the high-grade luminal narrowing of the left renal artery near their origins (short arrow).
common cause is traumatic, either from blunt or
penetrating trauma. In some cases aneurysms have
been associated with hypertension (Fig. 11). It is
debatable whether the aneurysm is the cause or
the result of the hypertension. If the aneurysm is the
cause it may be on the basis of altered flow within the
renal artery, external compression of the artery, or
from renal embolization. Surgical intervention should
be reserved for patients in whom there is a strong
belief that the aneurysm and hypertension are related
or in patients where there is a concern of aneurysm
rupture [6].
Renal artery dissection can occur either from
extension of an aortic dissection or within the renal
artery alone. Isolated renal artery dissection may be
associated with vasculitis; neurofibromatosis; Ehlers-
Danlos syndrome (type IV); and blunt or iatrogenic
trauma. The dissection leads to a narrowing of
the lumen and predisposes the artery to thrombosis.
This results in RAS or occlusion and can lead to
hypertension secondary to the renin-angiotensinme-
diated pathway.
CT angiography of the aorta and renal arteries
is commonly used in the evaluation of aortic dis-
section. The study not only allows for the detection
of the dissection, it also can be used to evaluate the
main abdominal arteries to see if any arise from the
false lumen. Dissection extending into the major
abdominal branches can be detected. In addition,
the scan provides anatomic detail that can aid in
surgical planning.
Treatment requires either surgical or percutaneous
intervention. In the case of an aortic dissection with
extension into the renal artery surgical repair of the
aorta and renal revascularization are necessary. In
isolated renal artery dissection the use of PTRA and
stents may be sufficient.
Polyarteritis nodosa
Polyarteritis nodosa is an arteritis of autoimmune
pathogenesis that tends to effect medium-sized and
small arteries in the body. Arteries anywhere in the
body can be affected, but the kidneys are the most
commonly affected sites. The disease is usually
bilateral but asymmetric resulting in transmural fi-
brinoid necrosis and surrounding inflammation about
the vessels. The vascular abnormalities can lead to
focal areas of ischemia or infarction in the kidneys.
These foci are likely a source of renin hypersecretion
leading to hypertension. Although most patients with
polyarteritis nodosa are eventually hypertensive,
hypertension is rarely an initial finding. Treatment
consists of corticosteroids and other immunosup-
pressants resulting in a 5-year survival rate of
approximately 80% [39].
The typical angiographic findings of polyarteritis
nodosa include abrupt angulations in the smaller
parenchymal renal arteries with irregularly margin-
ated lumens and multiple tiny aneurysms present and
scattered within the kidneys (Fig. 12). The disease is
often segmental in nature; areas of diseased kidney
can be adjacent to normal parenchyma. CT angiog-
raphy and MR angiography cannot demonstrate these
changes in the smaller vessels and conventional
Fig. 11. Renal artery aneurysms. (A) Superior to inferior view of three-dimensional axial maximum intensity projection image
through the renal hila from a CT angiogram demonstrates bilateral renal artery aneurysms in the renal hila (arrows). (B) Curved
planar reformatted image from the same patient.
angiography is recommended in patients suspected of
having polyarteritis nodosa.
Arteriovenous communications
Most arteriovenous communications are acquired
either iatrogenically or from penetrating trauma.
Rarely spontaneous arteriovenous communications
can occur within a neoplasm. Congenital arterio-
venous communications, or cirsoid aneurysms, usu-
ally manifest between the ages of 20 and 30 years,
with hypertension present in 25% of patients [6].
Hypertension in these patients is likely caused by
a steal phenomenon where the renal parenchyma
distal to the arteriovenous communication receives
less blood flow. This leads to ischemia and excessive
renin secretion.
The evaluation of suspect arteriovenous commu-
nications can be done with ultrasonography, CT, or
catheter-directed angiography. Ultrasound can image
the communication demonstrating high-velocity tur-
bulent blood flow within the communication. Renal
arteries feeding the communication and the draining
renal veins are enlarged.
Angiography demonstrates the communication
and enlarged vessels but also allows for the visualiza-
tion of the pathognomonic early contrast filling of
the renal veins during the arterial injection. This
phenomenon can also now be imaged with CT using
multiphase renal angiogram protocols that include an
early arterial phase [40].
Posttraumatic stenosis
Posttraumatic stenosis of the renal arteries is
usually the result of blunt trauma. The mechanism
is caused by shearing injury of the artery between the
relatively fixed proximal portion and the less fixed
middle third. This results in subintimal dissection or
hematoma with narrowing or occlusion of the lumen.
In cases where the injury does not resolve, the lesion
can progress to a permanent stenosis and hyperten-
sion can develop.
Depending on the severity of the initial trauma the
evaluation of the patient can differ. Often CT is
performed in this setting and in the case of a complete
occlusion a nonfunctioning kidney can be seen. In
patients with a posttraumatic stenosis, however, the
initial study can be normal in appearance. Catheter-
directed angiography is only performed in patients with
abdominal or pelvic injuries that necessitate its use.
CT angiography, MR angiography, or catheter-
directed angiography can be useful in the evaluation
of a patient with an acute onset of hypertension
following blunt traumatic injury. RAS discovered in
this instance, however, can be difficult to differentiate
from atherosclerotic disease or even FMD.
Renal parenchymal causes of hypertension
Renal parenchymal causes of renal-mediated hy-
pertension account for a very small percentage of
cases. Parenchymal diseases associated with hyper-
tension include glomerulonephritis; nephrosclerosis;
diabetic nephropathy and chronic pyelonephritis;
tumors, such as renal cell carcinoma and juxtaglo-
merular cell cancer; polycystic kidney disease; and
perirenal hematomas (Page kidney).
Glomerulonephritis
Glomerulonephritis is a disease that affects the
glomeruli of the kidneys. Acute glomerulonephritis
has a number of etiologies including infectious en-
tities; systemic diseases, such as lupus or Good-
pastures syndrome; or primary glomerular diseases.
In the acute phase of the disease the damage to the
Fig. 12. Polyarteritis nodosa. Selective injection of the right
renal artery during an intra-arterial digital subtraction angio-
gram demonstrates microaneurysms (arrows) of the intra-
renal arteries.
glomeruli results in proteinuria from leaky blood
vessels and a decrease in glomerular filtration rate.
The decreased filtration rate results in fluid and salt
retention that can lead to hypertension [6]. In most
cases an acute infectious glomerulonephritis resolves.
Glomerulonephritis from other causes, and occa-
sionally secondary to an infectious etiology, however,
can progress to chronic glomerulonephritis.
In chronic glomerulonephritis the damage to the
glomeruli continues over time with a slow progres-
sion of disease. This can eventually lead to renal
failure. Hypertension, caused by fluid retention and
occasionally renin hypersecretion, continues through-
out the course of the disease. The diagnosis of
glomerulonephritis is on the basis of renal biopsy.
Nephrosclerosis
Hypertension from any source can result in
changes within the renal arterioles. Initially there is
constrictive effect on the arterioles followed by
hypertrophy of the muscular walls. These changes
progress over time leading to increased vascular
resistance within the kidney itself. Although this
may not be a direct cause of hypertension these
changes may play a role in the lack of benefit seen
in some patients with corrected RAS. In patients with
chronic hypertension caused by RAS, revasculariza-
tion does not consistently produce a benefit [5]. Once
nephrosclerosis is present, the increased vascular
resistance within the kidney is not corrected by
revascularization of an affected kidney.
Diabetic nephropathy
There is a high prevalence of hypertension in renal
failure patients, depending on the type of nephropathy
and the severity of renal failure [41]. Renal insuffi-
ciency was thought to be a contributing factor in 1.8%
of patients with hypertension [42]. Diabetes is the most
common cause of end-stage renal disease in the
western world [43]. The damage to the kidneys is
believed to be a combination of hypertension and
nonhemodynamic effects of angiotensin II and aldo-
sterone on the kidney. The angiotensin II and aldoste-
r one ar e i mpl i cat ed i n t he f or mat i on of
tubulointerstitial fibrosis and glomerulosclerosis
[44]. The prevalence of hypertension in patients with
diabetic nephropathy is 87%. The diagnosis of diabetic
nephropathy is on the basis of renal biopsy.
Chronic pyelonephritis
Chronic pyelonephritis is an interstitial nephritis
caused by an infectious or inflammatory etiology.
The nephritis is characterized by an inflammatory
cellular infiltrate within the renal parenchyma. The
most common cause of chronic pyelonephritis is
severe vesicoureteral reflux and is often seen in
children. Other causes are anatomic abnormalities in
the kidneys that predispose the kidneys to repetitive
infection. These include calculi, obstruction, or a
neurogenic bladder [45].
The disease can be unilateral or bilateral and is
usually segmental. In chronic pyelonephritis from
Fig. 13. Chronic pyelonephritis. (A) Enhanced CT axial image obtained through the upper pole of the kidneys during the arterial
phase demonstrates focal regions of parenchymal scarring (arrow). There was no evidence of RAS on the three-dimensional
angiogram images (not shown). (B) Image obtained later in the examination during the excretory phase demonstrates underlying
caliceal clubbing and parenchymal scarring (arrow). Findings are characteristic of chronic pyelonephritis.
vesicoureteral reflux, the polar regions of the kidney
are most often involved. The changes in the kidney
are caused by parenchymal scarring, which results in
focal areas of parenchymal loss and blunting of the
subjacent calyx (Fig. 13). The disease often is
asymptomatic for a number of years.
CT, ultrasound, and MR imaging are capable of
depicting the changes in the renal contour associated
with this disease. In addition, voiding cystoure-
thrograms are helpful in the pediatric population to
document vesicoureteral reflux. In cases of chronic
pyelonephritis caused by reflux, reimplantation of
the ureter can resolve the reflux and stop further
renal damage.
Tumors
Juxtaglomerular cell tumor, or reninoma, is a rare
tumor of the kidneys that produces renin and leads to
hypertension. It is believed to be benign in nature and
often is only a few centimeters in diameter. The
tumor occurs in patients under the age of 20 up to
50% of the time.
Serum renin levels are elevated leading to second-
ary hyperaldosteronism and hypokalemia in addition
to hypertension. Other tumors, such as Wilms tumors
and renal cell carcinoma, and a variety of nonrenal
diseases can be associated with increased serum renin
levels, so this measurement alone is not specific. Ra-
diologic evaluation should consist of thin-section en-
hanced CTof the kidneys in the search for a solid mass.
Treatment of juxtaglomerular cell tumors consists
of complete surgical excision. This commonly leads
to remission of the hypertension assuming that
underlying hypertensive changes within the renal
arterioles has not occurred as described in the section
on nephrosclerosis.
In addition to juxtaglomerular cell tumors, hyper-
tension has been associated with renal cell cancer on
occasion. This is also caused by the release of renin
from the tumor [46]. The percentage of renal cell
carcinoma that produces sufficient amounts of renin
to cause hypertension is not known.
Polycystic kidney disease
Autosomal-dominant polycystic disease kidney
results in the replacement of the normal renal paren-
chyma with multiple cysts. As implied by its name the
disease is hereditary, but has a wide range of pheno-
typic presentations. In some patients much of the renal
parenchyma becomes replaced and can lead to end-
stage renal disease. Hypertension has been shown to
occur more commonly in patients with autosomal-
dominant polycystic disease kidney than their age-
matched controls. Hypertension in autosomal-domi-
nant polycystic disease kidney patients usually devel-
ops by the third or fourth decade, but can appear in
childhood or adolescence. The underlying cause of
Fig. 14. Autosomal-dominant polycystic kidney disease.
Coronal T2-weighted fast spin echo MR image through the
kidneys demonstrates multiple bilateral hyperintense lesions
in both kidneys consistent with renal cysts. The patient was
in their 20s and had a clinical diagnosis of autosomal-
dominant polycystic kidney disease with mild hypertension.
Fig. 15. Chronic subcapsular hematoma (Page kidney).
Enhanced CTscan through the midportion of the right kidney
demonstrates a subcapsular thick-walled low-attenuation
fluid collection with peripheral calcification in the wall
(arrow). The fluid collection displaces the kidney anteriorly
and compresses the renal parenchyma. The patient had a prior
history of blunt abdominal trauma. The patients hypertension
improved after surgical removal of organized hematoma.
the hypertension is unknown but may be multifacto-
rial including increased sodium retention, vascular
compression by cysts, and increased renin-angiotensin
II levels. The most likely cause is that increased renin
excretion from the kidneys results from increased
vascular resistance and focal parenchymal ische-
mia secondary to compression from the renal cysts
(Fig. 14) [47].
Subcapsular hematoma
Subcapsular hematomas are located between the
renal parenchyma and the fibrous renal capsule.
These can occur from many causes including trauma
or following a renal biopsy. In addition, renal tumors,
such as renal cell carcinoma or angiomyolipomas,
can spontaneously hemorrhage [40]. If there is a
sufficient volume of blood in the subcapsular space
the underlying renal parenchyma can be compressed.
Most often the hematomas resolve over time. On
occasion, however, the subcapsular fluid collection
does not resolve. This can lead to altered hemodynam-
ics within the compressed parenchyma and a localized
ischemia. On occasion, similar direct renal compres-
sion may be caused by perirenal fibrosis secondary to
perirenal hemorrhage [48,49]. The focal parenchymal
ischemia activates the renin-angiotensin II pathway
and hypertension can occur. This process is rare and is
known as a Page kidney. Evaluation with either
renal CT or MR imaging is best for depiction of the
subcapsular fluid collection and any possible varia-
tions in renal parenchymal enhancement (Fig. 15).
Definite management of page kidney includes percu-
taneous or surgical drainage of the hematoma, surgical
decapsulation and resection of the hematoma, and
partial or total nephrectomy. Renal vein renin sampling
may help predict the success of surgical intervention if
the affected side shows hyperreninemia.
Clinical evaluation
The role of a clinical evaluation in the detection of
renal-mediated hypertension is limited. Certain medi-
cal histories and physical findings can suggest RAS.
A recent history of trauma may provide evidence to
consider a dissection, posttraumatic stenosis, arterio-
venous communication, or potentially a page kidney.
Flank pain and hematuria can be associated with renal
tumors. In aortic dissection patients may complain of
a pain that radiates to their back. Many of these signs
or symptoms may not be present, however, despite
the underling disease and are of dubious usefulness.
Laboratory values are also often unreliable. In-
creased serum renin levels may be the result of a
juxtaglomerular cell tumor, but a significant number
of patients with essential hypertension also exhibit
elevated renin levels. In addition, other diseases may
result in elevation of serum renin levels.
Summary
There are many renal causes of hypertension.
Although RAS is the most common, other renal
lesions can result in hypertension. Any evaluation
of the kidney for hypertension should take all of these
potential renal etiologies into consideration.
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Evaluation of the hypertensive infant: a rational approach
to diagnosis
Christopher G. Roth, MD
a
, Stephanie E. Spottswood, MD
b,
*
,
James C.M. Chan, MD
c
, Karl S. Roth, MD
d
a
Department of Radiology, Boston Medical Center, Boston University School of Medicine, 88 East Newton Street,
Boston, MA 02118, USA
b
Department of Radiology, Virginia Commonwealth University Health System, 1250 East Marshall Street,
Post Office Box 980615, Richmond, VA 232980615, USA
c
Department of Radiology, The Barbara Bush Childrens Hospital, The Maine Medical Center,
22 Bramhall Street, Box 14, Portland, ME 04102, USA
d
Department of Pediatrics, Creighton University, 2500 California Place, Omaha, NE 69178, USA
The last half of the twentieth century witnessed an
explosion of technologic advances, which has revolu-
tionized medical care in particular. One area of med-
icine in which technologic applications have led to
major advances is the field of neonatology. Whereas
survival of an infant weighing 750 g in todays
intensive care nursery is hardly unusual, in the early
1960s even the son of President John F. Kennedy was
unable to survive at twice that weight. Yet, as with all
progress, it has come with a price. For example,
the relatively common procedure of umbilical artery
catheterization has resulted in an increase in renal
artery occlusion. Consequently, renal arterial occlu-
sion has assumed a prominent place on the differential
list for renovascular hypertension in infancy [1].
Although numerous authors have raised the level
of attention given to detection of hypertension in
infancy, consensus on a methodologic approach to
etiology has yet to be reached. As noninvasive or
minimally invasive imaging techniques continue to
improve, it becomes increasingly important to deter-
mine which is the most optimal for a given purpose
and when in an evaluation it is appropriate. This
article reviews and evaluates the pertinent literature
and uses this analysis to provide the basis for a
rational diagnostic approach to infantile hypertension.
Clinical aspects of diagnosis
One of the chief deterrents to routine blood pres-
sure measurement in infants has been the irreproduc-
ibility of results obtained using the inflatable cuff.
This is further complicated by reports that pressure is
affected by waking versus sleeping, abdominal palpa-
tion, sucking and feeding, position, crying, and agita-
tion [24]. Normal values for blood pressure in
children were defined in the Second Task Force
Report from the National Institutes of Health, pub-
lished in 1987 [5]. Standards were put forth for
children under a year and for term infants; the latter
have been corroborated by subsequent reports. Less
well-defined are normative data for prematurely born
infants, although it is generally agreed that normal
systolic and diastolic pressures are lower than in term
babies and correlate with body weight and chrono-
logic age [68]. Normal pressures tend to increase
from day to day over the first month, further compli-
cating the problem of definition [68].
In the neonate, precise definition of hypertension
remains controversial, with most authors using the
criteria of Adleman [9] delineated from a review of
doi:10.1016/S0033-8389(03)00072-1
E-mail address: sspottsw@hsc.vcu.edu
(S.E. Spottswood).
Radiol Clin N Am 41 (2003) 931944
the existing literature. These include a reproducible
pressure of greater than 90/60 in a term infant and
greater than 80/50 in the premature newborn. The
Adleman criteria were defined in 1978, however, and
subsequent data show much lower normal pressures
for very small infants who would not likely have
survived in 1978. The definition of hypertension for
the preterm baby, according to the Adleman criteria,
may be a significant overestimate. By contrast, defi-
nition of hypertension in infants younger than
12 months takes into account the difficulty of obtain-
ing reliable diastolic pressures and uses the systolic
pressure. A systolic pressure above the 95th per-
centile for age and height as determined by the
1987 study cited previously [5] taken at least three
times defines an abnormality.
Gruskin et al [10] have noted that morbidity
associated with hypertension increases proportionally
with the percentage elevation above the normal in
adults; using this as a guide, these workers have
defined a hypertensive crisis in a child as one in
which the blood pressure exceeds by 30% the age-
related norm. The difficulty in using this approach in
the infant younger than 12 months is the imprecision
of norms and of measurement of the blood pressure.
This is especially true of babies born prematurely, for
whom even the norms are practically difficult to
establish because of the rapid postnatal changes
taking place. Clearly, this area of definition is left
to the judgment of the individual physician to resolve
on a patient-to-patient basis.
Many causes of neonatal hypertension are, by their
nature, both curable and life threatening (Box 1). Even
such causes as renal artery thrombosis, from which
affected infants seem to recover without hypertensive
sequelae [11], are intrinsically life threatening and
demand diagnosis. It is the authors recommendation
that any infant with documented hypertension in the
first 6 months of life be treated with the respect due
any medical and diagnostic emergency.
Primary (essential) hypertension has not been well
documented to exist in infants and, in any event, must
be considered a diagnosis of exclusion. The corollary
of this is that the chief causes of infantile hyperten-
sion are secondary, of which approximately 70% are
renovascular [12,13]. The section that follows dis-
cusses a somewhat controversial issue: more sophis-
ticated imaging techniques, which may help to
localize subtle abnormalities of arterial circulation
in the kidney. Although great care is taken to include
discussion of all such methodologies available, ad-
vancing technology will undoubtedly create new ones
in the future, which require close scrutiny for their
usefulness of application in infants.
Box 1. Causes of hypertension in the
neonate
Renovascular causes
Catheter-associated
thromboembolic disease
Congenital renal artery stenosis
Mid-aortic coarctation
Renal vein thrombosis
Extrinsic renal artery compression
(hydronephrosis, hematoma, tumor)
Idiopathic arterial calcification
Congenital rubella syndrome
Renal parenchymal and cystic causes
Polycystic kidney disease
Multicystic-dysplastic kidney disease
Ureteropelvic junction obstruction
Unilateral renal hypoplasia
Congenital nephrotic syndrome
Tuberous sclerosis
Acute tubular necrosis
Acute cortical necrosis
Interstitial nephritis
Renal obstruction
Miscellaneous causes
Neoplasia
Neuroblastoma
Wilms tumor
Mesoblastic nephroma
Medication
Caffeine
Dexamethasone
Hypercalcemia
Vitamin D toxicity
Maternal drug addiction
(cocaine, heroin)
Neurologic
Seizures
Cardiovascular, pulmonary, and endocrine
causes
Thoracic aortic coarctation
Intracranial hemorrhage
Bronchopulmonary dysplasia
Pneumothorax
Congenital adrenal hyperplasia
C.G. Roth et al / Radiol Clin N Am 41 (2003) 931944 932
Radiologic aspects of diagnosis
An introduction to renal imaging
The goals of imaging are to detect those infants
who have renal artery stenosis as the cause of
hypertension, to predict curability following interven-
tion, and to identify those patients who have renal
parenchymal or structural abnormalities as the cause
of their hypertension. The same physiologic and
practical considerations that complicate blood pres-
sure measurement in infants also challenge the mo-
dalities charged with investigating the cause of
hypertension. The imaging modalities that have been
used in the evaluation of the hypertensive infant
include intravenous urography, renal scintigraphy,
ultrasonography, and angiography [14]. CT angiog-
raphy and MR angiography of the renal arteries have
been incorporated into the work-up of the adult
hypertensive, but have only anecdotal experience in
the infant.
Etiologic considerations in imaging
Fortunately, the history and physical examination
frequently suggest the underlying cause of hyperten-
sion in the infant. The potential causes are numerous
and the recognized imaging modalities, which are
variably invasive, often yield mutually exclusive data.
Most cases of hypertension in infants (see Box 1)
are caused by renovascular, renal parenchymal, or
cystic disease [1]. Renovascular disorders accounted
for 48% of neonatal hypertension in a recent study
[15]. Catheter-associated thromboembolic disease is
the most common offender in this category. The
mechanism is believed to be disruption of the vascular
endothelium of the umbilical artery following catheter
line placement, which initiates thrombus formation.
This may propagate directly or embolize to the renal
artery causing regions of ischemia or infarction with
increased renin release. Other renovascular etiologies
include congenital renal artery stenosis, mid-aortic
coarctation, renal vein thrombosis, and fibromuscular
dysplasia. Finally, extrinsic compression of the renal
artery can result from hydronephrosis; tumor; or
hematoma (eg, from adrenal hemorrhage) [16]. Renal
arteriography is the gold standard for the diagnosis of
renovascular disease in the adult. Treatment also may
be offered by angiography, because limited data in
the older pediatric population have shown that per-
cutaneous transluminal angioplasty can effectively
treat renovascular hypertension [1719]. As is dis-
cussed, however, angiography is less often performed
in the evaluation of neonatal hypertension, most
likely because of the technical difficulties and risks
of anesthesia.
Among renal parenchymal and cystic diseases
potentially causing infantile hypertension are poly-
cystic kidney disease (autosomal-recessive far more
commonly than autosomal-dominant); unilateral renal
hypoplasia; congenital nephrotic syndrome; and ac-
quired conditions, such as acute tubular necrosis, acute
cortical necrosis, and interstitial nephritis. Nonparen-
chymal renal causes of hypertension include uretero-
pelvic junction obstruction; vesicoureteral junction
obstruction; and renal obstruction from other causes,
such as calculi, blood clots, or other mass lesion.
The nonrenal causes of infantile hypertension (see
Box 1) constitute an array of conditions involving
different organ systems including endocrine condi-
tions, such as congenital adrenal hyperplasia; pulmo-
nary disorders, such as bronchopulmonary dysplasia
and pneumothorax; neoplastic entities, such as Wilms
tumor and neuroblastoma; neurologic conditions,
such as intracranial hypertension and seizures; and
miscellaneous causes, such as total parenteral nutri-
tion, hypercalcemia, adrenal hemorrhage, and medi-
cations including dexamethasone, adrenergic agents,
and others [1]. Most of the nonrenal causes can be
suggested by the history, physical examination, and
laboratory analysis.
Application of imaging to diagnosis of renal
parenchymal disease
Sonography
Because most cases of infantile hypertension are
caused by renal abnormalities, a diagnostic approach
focused on the kidneys is vital. Renal sonography is
typically used as the initial imaging modality in the
evaluation of the hypertensive infant because of its
convenience, accessibility, noninvasiveness, and lack
of radiation exposure. It is highly sensitive in detec-
tion of many of the parenchymal diseases of the
kidney (see Box 1), and for evaluating anomalies of
the renal collecting system. Sonography has replaced
the intravenous urogram as the initial imaging mo-
dality in the evaluation of infants and small children
with hypertension [20]. Sonography is comparable
with intravenous urography in the assessment of renal
size and hydronephrosis, without the risks of intra-
venous contrast administration and patient exposure
to ionizing radiation.
Sonographic evaluation of the kidneys is per-
formed with a combination of gray-scale, color Dopp-
ler, and duplex Doppler imaging. Gray-scale imaging
depicts a structural rendition of the kidney based on
acoustic interfaces (acoustic impedance differences
between adjacent tissues). Its primary use is for
anatomic detail. Color Doppler imaging superim-
poses a color-coded velocity flow scale, based on
the frequency shift of moving tissues, onto the gray-
scale image. Duplex Doppler imaging provides a
spectral trace recording frequency changes over time,
reflecting the velocity profile. The Doppler modalities
are useful for evaluation of vascular structures.
Gray-scale sonography. Gray-scale sonography is
initially used to assess the kidneys for any paren-
chymal or structural abnormality. Coronal, sagittal,
and transverse imaging of the kidneys is performed
with a high-resolution transducer to simulate a three-
dimensional viewof the renal parenchyma and collect-
ing system. The collecting system is evaluated for
hydronephrosis, which can result from ureteropelvic
junction obstruction, ureterovesicular junction ob-
struction, bladder outlet obstruction, or vesicoureteral
reflux. Hydronephrosis is easily perceived sonograph-
ically as dilatation of the renal collecting system.
Hydronephrosis without hydroureter is typical of con-
genital ureteropelvic junction obstruction; hydro-
nephrosis with hydroureter is apparent with
ureterovesicular junction obstruction or vesicoureteral
reflux. Renal size is assessed, and any asymmetry in
length greater than 5 mm may indicate unilateral renal
disease. Normal renal length in a full-term neonate
ranges from4 to 5.5 cm[21]. In the neonate and young
infant, the renal parenchyma demonstrates increased
cortical echogenicity because the glomeruli occupy a
larger volume of the cortex in infants (18%) as
compared with older children and adults (8.6%), and
20%of the loops of Henle are located within the cortex
rather than within the medulla [22]. Increased numbers
of anatomic structures in the cortex create an increased
number of interfaces for the ultrasound beam to
contact, resulting in increased cortical echogenicity.
Additionally, there is a relatively larger volume of
medulla in the neonatal kidney than in the adult kidney,
with cortico-medullary ratio of 1.64:1 in the neonate
and 2.59:1 in the adult [22]. This results in a striking
corticomedullary differentiation not seen in older chil-
dren and adults (Fig. 1). Loss of this corticomedullary
differentiation in the neonate reflects diffuse renal
disease or congenital dysplasia.
Renal cystic diseases are clearly depicted by
sonography. Autosomal-recessive polycystic kidney
disease characteristically reveals bilaterally enlarged
kidneys with diffusely and uniformly increased echo-
genicity and loss of the normal corticomedullary
differentiation. The individual cysts, which actually
represent dilated collecting ducts, are too small to be
resolved sonographically, but their numerous wall
interfaces produce exceptionally bright kidneys (in-
creased echogenicity) with ultrasound evaluation. Au-
tosomal-dominant polycystic kidney disease, which is
less common at this age, exhibits macroscopically
visible cysts of varying size. Mesoblastic nephroma,
often diagnosed in infancy, and Wilms tumor, usually
diagnosed in early childhood, manifest sonographi-
cally as a mass arising from the kidney. Wilms tumor
may be accompanied by tumor invasion of the renal
vein, which can also be detected sonographically.
Hypertension can occur as a result of increased renin
production by tumor cells [23].
In the infant with renal artery thrombosis, there is
little parenchymal abnormality in the acute phase of
vascular obstruction, but with time there is loss of
corticomedullary differentiation with diffusely in-
creased echogenicity, and decreased renal size, indi-
cating chronic ischemia. Chronically ischemic or
infarcted kidneys appear markedly shrunken and
abnormally echogenic (Fig. 2). Renal vein thrombosis
likewise exhibits poor corticomedullary differentia-
tion, but the affected kidney is enlarged. Thrombus,
usually manifested by intraluminal echogenic ma-
terial, may be detected in the renal artery or vein,
or in the abdominal aorta. Intraluminal thrombus,
however, occasionally appears anechoic (without
echoes, indistinguishable from the patent blood ves-
sel lumen) and color Doppler imaging is required to
demonstrate its presence.
Although the presence of echogenic thrombus
within the lumen of the aorta or the renal artery is
highly suggestive of thrombus, a recent study of
Fig. 1. Normal renal sonogram of 9-day-old infant with
hypertension. Sagittal image of the right kidney demon-
strates normal parenchymal echogenicity with good cortico-
medullary differentiation. Note normal, triangular-shaped,
hypoechoic renal pyramids. Duplex Doppler examination
was normal.
infantile hypertension has demonstrated no causal
relationship between the identification of renal or
aortic thrombus and renovascular hypertension [15].
Conversely, many normotensive patients fulfilled
gray-scale sonographic criteria for thromboembolism.
A prospective study using ultrasound to detect aortic
thrombus was positive in 12 of 71 patients in the
neonatal intensive care unit; only one of these pa-
tients developed hypertension and two normotensive
patients subsequently proved to have aortic thrombus
did not have sonographically detectable renal artery
thrombus [24].
The reported incidence of catheter-associated
thromboembolism in infants is highly variable, rang-
ing from 3.5% to 23% in autopsy series to 95% in
prospective ultrasound studies [25]. Clearly, it is a
common complication, and the presence of echogenic
intravascular material associated with systemic hyper-
tension is highly suggestive of renovascular disease;
however, earlier reports have demonstrated that gray-
scale imaging alone does not identify all cases of
renovascular hypertension. If the affected renal ves-
sels are beyond first-order branch vessels that cannot
be resolved reliably sonographically, and there are no
associated morphologic changes in the renal paren-
chyma, there is no gray-scale sonographic abnor-
mality. It is postulated that small-vessel renal disease
can be identified on gray-scale imaging as a dotted
corticomedullary junction [26].
Color Doppler imaging. Color Doppler imaging
can be used as an adjunct to gray-scale imaging in
the detection of intraluminal thrombus, which may be
isoechoic to flowing blood. Color Doppler imaging
can show absent flow distal to thrombus and the
presence of collateral vessels [27]. In addition to
renal vascular imaging, the abdominal aorta can be
examined from the diaphragm to the bifurcation in
the coronal plane, to look for disruption of color flow
by thrombus. Color imaging also is useful in distin-
guishing between anechoic renal hilar vascular struc-
tures from a similar-appearing dilated ureter or
collecting system.
The renal vasculature can be evaluated best sono-
graphically by duplex Doppler imaging. Various
quantitative and qualitative measures have been
designed to define renovascular disease. The classic
duplex Doppler findings in arterial stenosis are an
increase in blood flow velocity and spectral broad-
ening. Spectral broadening denotes a widening in the
spectrum of detected velocities, which is a manifes-
tation of turbulent flow through a stenotic segment.
Because renal blood flow is parabolic and the spec-
trum is inherently widened, however, spectral broad-
ening is not a valid means of defining turbulent flow
in the renal arteries [28].
Other objective measurements have been designed
to define sonographically renovascular hypertension.
The acceleration index and resistive index have been
used to identify renovascular hypertension [28]. The
acceleration index is determined by the intersection
of a line indicating the upstroke of systole with a line
drawn 1 second later perpendicular to the baseline;
the height of this line is divided by the ultrasound
frequency. The resistive index, a more commonly
used measurement, is the ratio of peak diastolic
velocity to peak systolic velocity (Fig. 3). Patriquin
et al [28] studied 20 children in whom renal artery
stenosis was suspected. Doppler tracings from at least
three segmental or intralobar arteries were obtained in
Fig. 2. Abnormal renal sonogram in young child with
renovascular hypertension. Sagittal sonogram reveals loss of
corticomedullary differentiation (compare with Fig. 1) and
focal areas of chronic cortical scarring (arrows). Note focal
upper pole caliectasis (white arrow).
Fig. 3. Spectral Doppler image in 1-year-old child with renal
artery stenosis. Resistive index (RI) is measured (electronic
cursors) as the ratio of the peak diastolic velocity to the peak
systolic velocity (RI = 1 [D/S]). In this case 1 (28.8/
83.5) = 0.66. Note normal Doppler waveform from the
renal artery.
each patient and the acceleration index and resistive
index calculated. Both indices were significantly
lower in stenotic arteries (the acceleration index to
a greater extent), with clear discrimination between
normal arteries and those with at least a 75% angiog-
raphic stenosis.
Normal renal arteries were associated with an
acceleration index of 4 to 7; renal arteries with at
least 75% stenosis ranged from 0.7 to 2.6. Although
used more commonly in practice, the resistive index
varied less with renal arterial stenosis with a resistive
index of 0.56 or less predicting stenosis with 95%
probability [28].
Conversely, a prospective study of hypertensive
children aged 12 days to 15 years defined a subset of
angiographically proved renovascular hypertensive
patients with negative Doppler examinations. The
Doppler ultrasound examinations, however, were
assessed qualitatively [29]. Specifically, they used
pattern recognition of the tardus-parvus phenomenon
[30], where pulsus tardus is the slowed, delayed
systolic upsweep, and pulsus parvus represents a
dampened maximal systolic peak, characteristic of a
severe stenosis (Fig. 4). The presence of multiple
renal arteries and segmental lesions accounted for
most false-negative Doppler examinations. In this
series, hypertensive patients with a negative duplex
Doppler examination generally had vascular lesions
amenable to endovascular or surgical treatment with a
high rate of success. It was concluded that for these
reasons Doppler sonography may be unreliable in the
evaluation of renal artery stenosis. The authors sug-
gested that with a negative Doppler sonogram and a
strong suspicion for renovascular hypertension, selec-
tive or superselective arteriography in association
with segmental venous renin sampling should be
performed because an angiographically demonstrated
causal lesion, if treated, most likely results in cure
[29]. Angiography is generally deferred in the
neonate, however, and medical treatment (often with
angiotensin converting enzyme inhibitors [ACEI]) is
the mainstay.
The aforementioned studies using Doppler ultra-
sound included very few infants. Technical factors,
including the inherent difficulty in obtaining Doppler
signal from multiple intrarenal vessels, the long
duration of the examination, and the frequent lack
of visualization of the proximal renal vasculature
because of bowel gas, challenge the implementation
Fig. 4. Renal sonogram with spectral Doppler image in
1-year-old child with renal artery stenosis demonstrating
tardus-parvus phenomenon. Duplex Doppler spectral tracing
of the left renal artery reveals delayed and dampened systolic
upsweep (arrow) typical of renal artery stenosis (note
continuous venous waveform below the line). Compare with
normal renal arterial waveform in Fig. 3.
Fig. 5. Renal arteriogram in a 3-year-old patient with
uncontrollable hypertension and history of neurofibroma-
tosis. Middle aortic syndrome with renal artery stenosis.
Aortic arteriogram reveals marked, long-segment stenosis
and irregularity of the aorta extending from the suprarenal
region to just above the bifurcation. The right renal artery is
occluded at its origin (curved arrow) and the left renal artery
(straight arrow) is markedly stenotic. Note also occlusion of
the hepatic artery (large arrow). There is marked enlargement
of the inferior mesenteric artery and left colic artery
(arrowheads), and multiple lumbar arteries. (Courtesy of
Jaime Tisnado, Medical College of Virginia, Richmond, VA.)
of this technique at all, let alone in infants. Multiple
additional factors further complicate the application
of such techniques in the neonatal ICU, including the
use of portable machines; the presence of life support
lines and tubes; and the likelihood that the patient is
dependent on mechanical ventilation, which renders
duplex Doppler sonography virtually impossible (es-
pecially in the setting of high-frequency ventilation).
Sonography is a versatile modality that offers
several parameters for evaluating the hypertensive
infant. The implementation of duplex Doppler sonog-
raphy is limited by operator skill and experience and
by the technical difficulties in performing this tech-
nique in the intensive care setting. In the persist-
ently hypertensive neonate in which duplex Doppler
sonography is not technically feasible, the identifica-
tion of intraluminal thrombus on gray-scale imaging
suggests the diagnosis. The absence of intraluminal
thrombus on gray-scale imaging, however, does not
exclude renovascular hypertension and further diag-
nostic investigation should be pursued.
Angiography
The accuracy of Doppler sonography in the diag-
nosis of renal artery stenosis has been compared with
renal angiography, which is considered the gold
Fig. 6. Technetium (Tc) 99m MAG3 ACEI renogram in a 13-day-old infant with unexplained hypertension. (A, B) Normal
baseline study. Posterior images of the kidneys were obtained following the intravenous administration of Tc 99m MAG3 (initial
flow images were unremarkable) (A). Note symmetric uptake and excretion of tracer, followed by visualization of the urinary
bladder. Normal time-activity curve demonstrates peak renal activity at 3 minutes (normal) and a differential function of 48.8%
(left kidney) and 51.2% (right kidney) (B). (C, D) Normal enalaprilat study. Posterior images of the kidneys were obtained
following the intravenous administration of enalaprilat, followed by intravenous Tc 99m MAG3 (C). Peak renal activity on the
time activity curves is demonstrated at 2 minutes (normal) (D). There is normal differential function: 45% (left kidney) and 55%
(right kidney), and no significant renal cortical retention of tracer.
standard in the evaluation of renovascular hyperten-
sion [14,15,20]. Despite the high incidence of reno-
vascular hypertension in children relative to adults,
the use of renal arteriography in children has been
limited. The necessity for general anesthesia generally
preempts the use of conventional arteriography in
infants. Catheter-related vascular injury and radiation
exposure are other potential adverse considerations.
Although intra-arterial digital subtraction arteriogra-
phy requires substantially less intravascular contrast
material and shortens the duration of the procedure
compared with traditional arteriography, resulting in
less radiation exposure, it has not substantially in-
creased the use of arteriography in the diagnosis of
infantile hypertension. When performed, digital sub-
traction arteriography images may be compromised by
the presence of bowel gas, although both intravenous
glucagon and abdominal compression can mitigate this
problem [31]. Intravenous digital subtraction arteriog-
raphy has been attempted as an alternative to arteriog-
raphy in the evaluation of renovascular hypertension
with limited success. Intravenous digital subtraction
arteriography requires a higher contrast load and the
vessels of interest are frequently not well opacified by
this technique. Lesions beyond the first-order branch
vessels are not demonstrated by intravenous digital
subtraction arteriography and this technique has been
essentially abandoned in the evaluation of the hyper-
tensive infant [20].
The potential benefit of arteriography in the
evaluation of the pediatric hypertensive patient is the
opportunity for definitive treatment. Percutaneous
transluminal angioplasty has been demonstrated to
be effective in the adult population and has recently
been applied to the pediatric population with success
[17,18]. Nonetheless, virtually no data are available
regarding the use of percutaneous transluminal angio-
plasty in infants. The highest rate of success in
children has been associated with nonostial, short-
segment main renal arterial lesions; the technical
difficulty in traversing ostial lesions, with or without
aortic involvement, often precludes successful angio-
plasty [32].
Most angiographically demonstrated lesions in
cases of pediatric hypertension are related to intrinsic
vascular disorders, such as fibromuscular dysplasia,
neurofibromatosis, and other undifferentiated vascu-
litides. During arteriography, pharmacologic maneu-
vers, such as epinephrine infusion, can determine the
hemodynamic significance of renal arterial lesions.
One of the inherent advantages of angiography is that
the main renal artery, and the intrarenal segmental,
subsegmental, and any accessory renal arteries are well
demonstrated and any of these vessels may be affected
Fig. 6 (continued).
in the previously mentioned disorders (Fig. 5). Al-
though these entities do occur in infants, they are not
typically the chief diagnostic considerations in this age
group, especially in neonatal patients.
In infants, the most common underlying abnor-
mality is catheter-related thromboembolism. Aortic
and renal arterial thrombus can be demonstrated with
contrast aortography and renal arteriography per-
formed by the offending umbilical artery catheter
[25]. Many studies have proved the efficacy of
arteriography in documenting the presence of throm-
bus in association with umbilical arterial cathe-
terization. There has been very poor correlation,
however, between the presence of thrombus and
clinical signs and symptoms. The variably reported
incidence of arterial thrombus associated with um-
bilical artery catheterization is high enough that it
may be an incidental finding in some instances. In
any event, catheter-associated aortic and renal arte-
rial thrombus has been treated relatively successfully
with medical therapy and not with percutaneous
transluminal angioplasty, which argues against the
implementation of arteriography [1,15,33]. Because
the usual first-line therapy in neonatal renovascular
hypertension is ACEI and revascularization is gen-
erally not an option, it is more important to identify
cases of bilateral renal ischemia and renal ische-
mia in a solitary kidney in which ACEI therapy
is contraindicated. Renal scintigraphy is the least
invasive and most reliable means of providing
this information.
Renal scintigraphy
Renal scintigraphy can yield valuable functional
data with variable anatomic detail. In the presence of
unilateral renal artery stenosis, conventional radio-
nuclide scintigraphy may show evidence of relatively
diminished renal perfusion and function of the affect-
ed kidney. Because of the autoregulatory mechanism,
however, mediated by the renin-angiotensin system,
Fig. 6 (continued).
the glomerular filtration rate (GFR) may be main-
tained at a normal level and the scintigram may be
normal. Performing the examination in conjunction
with an ACEI greatly increases the sensitivity and
specificity of renal scintigraphy for detecting hemo-
dynamically significant renal artery stenosis; the
sensitivity and specificity are each approximately
90% [34].
When renal arterial stenosis reaches 60% of the
cross-sectional diameter of the artery, the kidney
responds by increasing its output of renin, stimulating
production of angiotensin II, which augments falling
GFR by increasing tone in the efferent arterioles at
the cost of generalized vasoconstriction, resulting in
systemic hypertension [14]. The administration of an
ACEI blocks the production of angiotensin II, which
decompensates renal function.
An ACEI scintigraphy capitalizes on this physio-
logic compensation mechanism. A baseline renogram
is first performed, which may be normal with a renal
arterial stenosis of up to 70% to 80% [14]. Beyond
this range, renin-angiotensin compensation may be
incomplete and the baseline study may show dimin-
ished function. If the kidney has infarcted and there is
no residual function, the baseline study results in
nonvisualization of the involved kidney.
If the baseline study is normal, the administration
of the ACEI eliminates the renin-angiotensin compen-
sation and thereby decreases the renal perfusion
commensurate with the degree of stenosis. This trans-
lates to a decrease in function in the well-compensated
kidney. There is high probability of hemodynami-
cally significant renal artery stenosis when there is
(1) marked change in the renogram curve, (2) unilat-
erally reduced relative uptake of tracer, or (3) unilat-
erally prolonged renal and parenchymal transit time.
In cases of very severe renal artery stenosis (up to
95%) there is no significant change from baseline after
ACEI administration with at most minimal residual
renal function. When renal arterial stenosis has
resulted in complete obstruction, the baseline scinti-
gram may demonstrate some blood pool activity
caused by collateral vessels and there is no change
after ACEI.
Renal scintigraphy for the evaluation of renal artery
stenosis can be performed with a choice of ACEI:
captopril or enalaprilat. Enalaprilat is administered
intravenously, and unlike orally administered capto-
pril, its pharmacologic effect is not dependent on rate
of gastrointestinal absorption. ACEIs can cause sig-
nificant hypotension; blood pressure and heart rate are
monitored before and during ACEI administration.
Fig. 6 (continued).
The baseline and follow-up ACEI scintigraphy
can be performed with either glomerular or tubular
radiopharmaceuticals. The original studies performed
in pediatric patients used a glomerular agent, Tc 99m
diethylenetriamine pentaacetic acid (DTPA) with
captopril [35]. Subsequently, Tc 99m mercaptoacetyl-
triglycine (MAG3), a tubular agent, has been used for
ACEI renography. It is preferred over Tc 99m DTPA
in patients with elevated serum creatinine, because of
its higher renal extraction.
The disposition of glomerular agents in the kidney
is dependent on the GFR; the rate of accumulation of
radiotracer is directly proportional to the GFR. The
rate of glomerular agent accumulation can be
expressed as the slope of the curve of computer-
generated graphs at fixed intervals and differential
renal function of each kidney can be derived (Fig. 6).
With Tc 99m DTPA, the scintigraphic manifestation
of decreased renal function following ACEI adminis-
tration is decreased extraction and delayed appearance
Fig. 7. Tc 99m MAG3 renogram. Renal artery stenosis in an older child with hypertension. (A) Posterior images of the kidneys
were obtained following the intravenous administration of enalaprilat (initial flow images were unremarkable). The early images
reveal reduced tracer uptake and function of the relatively smaller right kidney, whereas the normal left kidney reveals normal
accumulation and ureteral excretion of tracer. The delayed images demonstrate marked retention of tracer in right kidney (arrow),
consistent with hemodynamically significant renal artery stenosis. (B) Normal baseline Tc 99m MAG3 renogram. (Courtesy of
Massoud Majd, Childrens National Medical Center, Washington, DC.)
of the radiotracer in the collecting system. The affected
kidney demonstrates relatively decreased uptake.
Tubular agents are secreted by the proximal
tubules, a function that is maintained in the setting
of a falling GFR. As urine production in the ischemic
kidney decreases after ACEI administration, the tu-
bular agent accumulates and remains in the cortex
because of the fall in urine production. The affected
kidney demonstrates parenchymal retention of tracer
(Fig. 7). Tc 99m MAG3 has an advantage over Tc
99m DTPA in that the images are of higher resolu-
tion, and measurements of residual cortical activity
can be displayed graphically (see Fig. 7).
In hypertensive neonates without an umbilical
arterial catheter, an abnormal ACEI study indicates
renal artery stenosis. A more common cause of
hypertension in neonates, however, usually transient,
is narrowing of the renal artery because of thrombosis
as a complication of the umbilical artery catheter
(Fig. 8). The value of ACEI renography in these
neonates is to determine whether it is safe to treat
them with ACEI therapy.
Fig. 8. Tc 99m MAG3 renogram. Renal artery thrombosis. Neonate who became hypertensive a few days following umbilical
artery catheter placement. (A) Initial posterior images obtained following administration of enalaprilat reveal a normal-appearing
right kidney, and a smaller, irregularly contoured left kidney, presumably developmental. Delayed images reveal normal
excretion from the left kidney, but marked retention of MAG3 in the right kidney (arrow) caused by partial obstruction of the
renal artery. Time-activity curves generated from region of interest drawn around the right kidney demonstrate (B) normal pre-
ACEI function of the right kidney (pre-captopril) and (C) impaired post-ACEI function (post-enalaprilat). (Courtesy of Massoud
Majd, Childrens National Medical Center, Washington, DC.)
In addition to its high sensitivity and specificity
for hemodynamically significant renal artery stenosis,
a major benefit of ACEI renography is that a positive
study indicates a high probability that blood pressure
is reduced following angiographic intervention [31].
Although this procedure has been performed safely in
young children [18], subsequent intervention with
percutaneous transluminal angioplasty is an unlikely
consideration in the young infant.
Future considerations for imaging diagnosis
CT angiography of the renal arteries has had
promising results in the detection of renal artery
stenosis in the adult population. New developments
in CT technology, including spiral CTand multidetec-
tor CT, allow volumetric acquisitions during a single
breathhold. The volume of acquired data can then be
reformatted for display in any plane. Sensitivity and
specificity for detection of hemodynamically signifi-
cant renal artery stenosis in the adult population have
been as high as 92% and 83%, respectively [36], and
90% and 97%, respectively [37]. High sensitivity and
specificity for this modality may be caused by the
ostial location of stenotic lesions seen in adults. Al-
though little data are currently available describing use
of CT angiography in infants and children, potential
advantages include relative speed of image acquisition
(which may obviate need for sedation), and minimal
invasiveness, as compared with angiography. Potential
disadvantages include inability to breathhold, and
limitations in the evaluation of small accessory, seg-
mental, or intrarenal arteries [37], which unfortunately
are frequently involved in infants with renal artery
stenosis. Additionally, larger doses of intravenous
contrast are required with CT angiography than with
intra-arterial digital subtraction arteriography [37].
As with CT angiography, little data are available
on the use of MR angiography of the renal arteries in
infants. Anecdotally, MR angiography has been
attempted by one of the authors, in an infant with
intractable hypertension, and in an older child with
middle aortic syndrome. Limitations were difficulty
resolving the small renal arteries, motion artifact
during imaging, and the need for sedation for this
relatively long study. Obvious advantages include
lack of ionizing radiation or intravenous contrast.
Summary
This article reviews the literature and describes a
methodologic approach to the diagnosis of hyperten-
sion in the young infant. The numerous etiologies of
hypertension have been discussed and normative
blood pressure data for neonates and infants have
been provided. Techniques for accurate blood pres-
sure measurement in the intensive care setting and for
routine outpatient settings, are discussed.
The lengthy discussion of radiologic approach
to imaging can be summarized with the following
suggested algorithm. Initial screening should be per-
formed with gray-scale sonography, to identify renal
parenchymal or collecting system abnormalities, in-
cluding mass lesions and congenital anomalies.
Further imaging with color and duplex Doppler
sonography detects renal arterial or aortic thrombosis,
and alterations in the arterial waveform caused by
intrinsic or extrinsic renal artery narrowing. The major
limitation of Doppler sonography is the recognition
that disease in accessory renal arteries or in small
segmental intrarenal arteries may frequently be unde-
tected. Functional imaging with ACEI renography
should follow renal sonography to detect hemo-
dynamically significant renovascular disease (with a
sensitivity and specificity of approximately 90%);
intravenous enalaprilat is the preferred ACEI.
Angiography should be reserved for older children
in whom interventional percutaneous angioplasty may
be more feasible. A young infant with hypertension
caused by renal artery stenosis should be controlled
medically until he or she is large enough to undergo
angiography and angioplasty successfully. CT angiog-
raphy and MR angiography, although promising in the
adult population, may not adequately resolve the small
intrarenal vessels, which are frequently the culprit in
renovascular hypertension of infancy.
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CT urography and MR urography
Akira Kawashima, PhD, MD
*
, James F. Glockner, MD, Bernard F. King, Jr, MD
Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
The uroradiologic evaluation of patients with
common and complex disease is changing rapidly.
Intravenous (excretory) urography has been the initial
evaluation for upper tract imaging in patients with
hematuria, flank pain, and other urologic diseases for
the past three decades [1,2]. The imaging investiga-
tion of hematuria usually began with an abdominal
radiograph for the detection of opaque urinary calculi.
Since Smith et al [3] demonstrated the value of
unenhanced CT for the evaluation of patients with
acute flank pain in comparison with intravenous
urography in 1995, in many centers intravenous
urography has been replaced by unenhanced CT for
evaluation of patients with suspected ureteral calculi.
The remaining major indication for intravenous urog-
raphy is hematuria.
Patients with hematuria require evaluation of both
the renal parenchyma and the urothelium. Intra-
venous urography remains the initial imaging modal-
ity of choice for assessing the upper urinary tract. The
limitations of intravenous urography are frequently
complemented with the supplemental use of ultra-
sound, CT, or MR imaging, however, to help evaluate
the renal parenchyma and detect renal masses [4].
Intravenous urography with nephrotomography can
identify only 21%, 52%, and 82% of masses less than
2 cm in diameter, 2 to 3 cm, and 3 cm or larger,
respectively, when CT is used as the reference stan-
dard [5]. Moreover, when a mass is detected by
intravenous urography, further characterization by
cross-sectional imaging is necessary because intra-
venous urography cannot reliably distinguish solid
masses from cysts.
CT imaging has evolved from single-detector into
multidetector row helical volumetric acquisition tech-
niques, and these advances have had a significant
impact on imaging of the urinary tract. Application of
multidetector row helical volumetric CT evaluation of
the urinary tract has been termed CT urography.
The concept of CT urography is attractive because
both the renal parenchyma and urothelium can be
evaluated at a single comprehensive examination.
This primary use of CT urography potentially allows
shortening the duration of the diagnostic evaluation in
many patients. CT urography is becoming the defin-
itive study for patients with hematuria.
Another alternative to conventional imaging of the
urinary tract is MR urography. MR urography using
either heavily T2-weighted pulse sequences or gado-
linium-enhanced T1-weighted sequences has shown
potential to detect, localize, and characterize collect-
ing system abnormalities. Because neither iodinated
intravenous contrast nor ionizing radiation is used, it
is safe in patients with contraindication to iodinated
contrast media, in young patients, and in pregnant
women [68].
Although there continues to be a lack of rigorous
large-scale research on the cost-effectiveness of var-
ious urographic imaging strategies in the evaluation
of patients with hematuria and other urologic indica-
tions, sufficient information exists to define a reason-
able approach to patients with hematuria. This article
describes the evaluation of hematuria and reviews
developing concepts and evolving techniques of CT
and MR urography.
Evaluation of patients with hematuria
Hematuria is extremely common and can originate
from any site in the urinary tract. The presence of
doi:10.1016/S0033-8389(03)00073-3
E-mail address: kawashima.akira@mayo.edu
(A. Kawashima).
Radiol Clin N Am 41 (2003) 945961
gross hematuria usually prompts patients to seek
medical attention, and a thorough urologic investiga-
tion is warranted to determine its cause. In contrast,
the diagnosis, etiology, and management of asymp-
tomatic microhematuria are controversial. Asymp-
tomatic microscopic hematuria is often not a sign of
underlying surgical urologic disease. Some degree of
hematuria is identified in 9% to 18% of normal
individuals [9,10]. Routine screening of adults for
microscopic hematuria with dipstick testing is not
recommended because hematuria associated with
significant urologic disease may be intermittent. Once
asymptomatic microscopic hematuria is documented,
however, the patients should be evaluated. The defi-
nition of microscopic hematuria recently recommen-
ded by the American Urological Association is three
or more red blood cells per high-power field on
microscopic evaluation of the urinary sediment from
at least two of three properly collected urinalysis
specimens [9]. Patients with risk factors for signifi-
cant urologic disease should be considered for a
urologic evaluation after one episode of properly
documented microscopic hematuria [9,11]. These risk
factors include the development of gross hematuria or
irritable voiding symptoms; a history of smoking or
chemical exposure; all adults older than 40 years;
previous urologic history; a history of urinary tract
infection or pelvic irradiation; analgesic abuse (eg,
phenacetin); and cyclophosphamide exposure [11].
When hematuria is accompanied by other findings
(eg, proteinuria, red blood cell cast, elevated serum
creatinine), a medical evaluation for the presence of
primary diffuse renal parenchymal disease is re-
quired. Patients without these findings and those with
risk factors for significant urologic disease should be
referred promptly for a urologic evaluation [11].
Microscopic hematuria associated with anticoagula-
tion therapy frequently is precipitated by significant
urologic pathology and prompt evaluation is required.
In a study of 1000 consecutive adults with asymp-
tomatic gross or microscopic hematuria by Mariani
et al [12] in 1989, 9% of patients were found to have
life-threatening abnormalities, and an additional 23%
had lesions requiring at least observation.
Cystourethroscopy is performed to complete the
evaluation of the lower urinary tract, primarily the
bladder, although gross bladder pathology can be
visualized with imaging studies. Comprehensive up-
per tract imaging studies should be used to detect
renal cell carcinoma, transitional cell carcinoma,
urolithiasis, and renal infection. Because the renal
parenchyma is evaluated better by cross-sectional
imaging modalities than by intravenous urography, a
primary issue when using these cross-sectional tech-
niques is whether CTand MR urography can visualize
urothelial abnormalities of the intrarenal collecting
systems and ureters with sensitivities equal or superior
to that of conventional intravenous urography.
CT urography
CT urography is increasingly performed as a de-
finitive study for the investigation of hematuria and
other urologic indications [13]. The renal parenchyma
is evaluated with axial CT scans, and then the intra-
renal collecting systems and ureters are visualized by
one of two general approaches. One approach uses
projection radiographs (conventional film-screen ab-
dominal radiographs, computed digital radiographs,
and CT scanned projection radiographic [SPR]
images). A second approach uses thin-section axial
CT images obtained during the excretory phase of
enhancement with two-dimensional multiplanar refor-
mation and three-dimensional reconstruction images.
These two different CTurographic techniques are both
attractive because they attempt to combine the sensi-
tivity and specificity of CT for urinary calculi and
small renal masses with the sensitivity and specificity
of intravenous urography for urothelial abnormalities
into one minimally invasive examination [14].
Combining CT and projection radiography
Intravenous urography remains the gold stan-
dard for noninvasive visualization of intraluminal
filling defects in the collecting systems and uro-
thelial abnormalities. Previous series examining
patients with hematuria have been based on this
intravenous urography technique. Combined (hy-
brid) CT and conventional intravenous urography
methods have been implemented to incorporate the
strength of each modality into a single examina-
tion. When projection radiography is used, no CT
postprocessing is necessary.
In 1996, Perlman et al [15] first described the
concept of CT urography. Conventional intravenous
urograms were obtained in a urography suite, followed
by patient transfer to a CT suite for supplemental CT
without additional intravenous contrast adminis-
tration, which was limited to the kidneys and any
additional abnormality identified on intravenous urog-
raphy (Fig. 1). In 27 of 30 patients with lesions in the
collecting system, the lesions were detected only on
intravenous urography. This technique allowed a rea-
sonable evaluation of the renal parenchyma but lost the
advantage of unenhanced CT compared with intrave-
nous urography in detecting urolithiasis.
A. Kawashima et al / Radiol Clin N Am 41 (2003) 945961 946
Fig. 1. Transitional cell carcinoma of the left ureter in a 71-year-old man with a history of gross hematuria. (A) Prone view of
intravenous urogram demonstrates an irregular filling defect in the mid left ureter (arrow) distal to unifying two left moiety ureters
in the partial duplication of the left renal collecting system. (B) CT scan at 3.75-mm slice thickness following the intravenous
urogram (Fig. 1A) without additional intravenous contrast administration reveals a soft tissue mass of the left ureter (arrow)
partially surrounded by contrast material at the level of the aortic bifurcation. (C) Curved planar reformation image demonstrates
the left ureteral mass (arrow). The patient underwent left segmental ureteral resection for noninvasive grade 2 (of 3) papillary
urothelial carcinoma.
In other centers, an abdominal radiograph is first
obtained. Unenhanced and enhanced helical CT
images are next acquired to evaluate renal parenchy-
ma and urolithiasis. Finally, the patient is transferred
to the urography suite to complete the urographic
portion of the study. This approach combines the
advantages of intravenous urography with those of
CT scanning, allowing one comprehensive imaging
study. Movement of the patient between procedure
rooms, however, requires additional time, can cause
scheduling and staffing conflicts, and often affects the
level of pyelocalyceal distention in the urographic
portion of the examination.
An alternative to this approach, which was imple-
mented at the authors center, is the acquisition of
conventional radiographs with a ceiling-mounted
overhead x-ray tube while the patient is lying on the
CT table for multiphasic CT acquisitions [1618].
Fig. 2. Transitional cell carcinoma of the right intrarenal collecting system in a 76-year-old woman with gross hematuria.
(A) Intravenous urogram 8 minutes after intravenous contrast material injection with ureteral compression reveals an irregular
round filling defect occupying a mid renal calyx (arrow). (B) Corresponding original CT scanned projection radiographic (SPR)
image obtained at 80 kV and 300 mA demonstrates objectionable dark band along high-density objects, such as iodinated
contrast material. The caliceal mass (arrow). (C) Enhanced CT SPR image after reprocessing the original CT SPR image data
(Fig. 2B) using clinically optimized algorithms substantially minimizes the artifacts and appears similar to that of conventional
intravenous urogram (Fig. 2A). The caliceal mass (arrow). (D) Excretory phase enhanced CT scan at 1.25-mm slice thickness
demonstrates a small soft tissue mass (m) occupying a minor calyx of the interpolar region of the right kidney. (E, F) Coronally
reformatted (E) and thin (8 mm) slab maximal intensity projection (MIP) (F) images demonstrate the relationship of the soft
tissue mass to the intrarenal collecting system. (G) Thick (5 cm) slab average intensity projection (AIP) image demonstrate an
overview of the renal collecting system similar to intravenous urogram (Fig. 2A). The caliceal mass (arrow). The patient
underwent right nephroureterectomy for noninvasive grade 2 (of 3) papillary transitional carcinoma located in a minor calyx.
This method allows high-spatial-resolution intrave-
nous urography films (approximately four line pairs
per millimeter for film-screen radiography) to be
obtained at various times before and after the CT
acquisitions without the need for the patient to move.
The technique requires the use of an auxiliary, radio-
lucent CT tabletop that can accommodate a radio-
graphic cassette under the patient without introducing
artifacts on the CTimage [18]. This approach has been
accepted as an integrated urologic imaging study at
Fig. 2 (continued).
the authors institution (Figs. 2, 3) [16]. In the authors
clinical experience, urothelial abnormalities are better
or only seen on conventional film-screen urograms,
which comprise 10% of abnormalities revealed on CT
urography examinations [16]. This underscores the
need for high-quality urographic images in CT urog-
raphy. Excretory-phase enhanced CT scans can be
acquired to correlate with positive or inconclusive
projection urographic findings when necessary.
An alternative method of obtaining projection
images without moving the patient off the CT table
is the use of the CT SPR technique. A CT SPR image,
which is referred to as a scout view (GE Medical
Systems, Milwaukee, WI), topogram (Siemens
Medical Systems, Iselin, NJ), and scanogram, is
usually used for prescan localization. The spatial
resolution of CT SPR (approximately less than one
line pair per millimeter) when obtained at 80 kV and
300mA is inferior to conventional radiography,
whereas the contrast resolution of opacified structures
is similar to conventional radiography [17]. Conven-
tional CT SPR images use simple edge enhancement
image filters, however, that result in dark and bright
band artifacts around high-attenuation objects (eg,
iodinated contrast media) (see Figs. 2B, 3B) [17].
These objectionable artifacts around high-contrast
objects can be minimized substantially on new im-
proved CT SPR with reprocessing techniques that use
clinically optimized contrast-enhancement algorithms
while maintaining adequate high-contrast spatial reso-
lution (GE Medical Systems) (see Figs. 2C, 3C)
[19,20]. This CT urographic approach, combining
helical CT and enhanced CT SPR urographic images,
is attractive because modification of the CT tabletop
and installation of a ceiling-mounted x-ray tube are no
longer necessary, and this technique can be performed
on any multidetector helical CT scanner. As with the
reformatted CT images of the collecting system,
further scientific studies are needed to validate the
sensitivity of optimally enhanced CT SPR images for
depicting fine urothelial detail.
Bowel preparation with a mild laxative before
urography examination usually helps to reduce the
amount of fecal material and gas in the colon so that
the intrarenal collecting systems can be visualized
more clearly with projection radiographs. Diuresis
after the ingestion of moderate quantities of fluid or
mild diuretics, such as coffee or tea, decreases the
Fig. 2 (continued).
concentration of contrast material in the urinary tract
during the excretory phase of the examination. This
and further swallowing of gas may be prevented by
instructing the patient to take nothing by mouth for
several hours before the examination.
Visualizing the intrarenal collecting system and
ureter with intravenous urography depends on opti-
mal distention and opacification. After completion
of intravenous contrast material injection, ureteral
compression is applied unless contraindicated (eg,
abdominal aortic aneurysm, recent abdominal sur-
gery, severe abdominal pain, suspected renal trau-
ma, and urinary diversion or renal transplant) [2].
The use of ureteral compression is important to
ensure adequate pyelocaliceal distention, especially
when low-osmolar iodinated contrast material is
used [1,2]. The intrarenal collecting system and
proximal ureters are well distended on 8-minute
delayed film, and their appearance with and without
compression can be studied [1]. The ureters are
generally well visualized on 10-minute decom-
pressed film. Twenty-minute film and postvoid film
are optional and may be useful for the morphologic
evaluation of the bladder. The evaluation of the
entire urinary collecting system usually requires
review of a composite of urographic images.
Consideration of radiation exposure is very im-
portant with these new techniques. One abdominal
radiograph with a stationary grid obtained in a 21-cm-
thick patient delivers an effective skin exposure level
Fig. 3. Ureteritis cystica in the left ureter in a 60-year-old woman with a history of left renal stone. (A) Intravenous urogram
8 minutes after intravenous contrast injection with abdominal compression demonstrates numerous tiny smooth uniform-sized
filling defects in the left ureter (arrows). (B, C) The appearance of the small urothelial filling defects on enhanced CT SPR image
(C) is more similar to conventional intravenous urogram (Fig. 3A) than original CT SPR image (B) by minimizing the edge
enhancement artifacts. (D) CTscan at 1.25-mm slice thickness obtained during the excretory phase of enhancement demonstrates
a tiny focal intraluminal elevation of the mid left ureteral wall (arrow). (E) Oblique coronal reformatted image demonstrates
many tiny filling defects in the left ureter (arrows). (F, G) The small urothelial filling defects are less well defined on thick (5 cm)
slab MIP (F) and AIP (G) images.
of 412 mR (106.3 mC/kg) and effective dose of
0.5 mSv [17]. The effective skin exposure and
effective doses at conventional radiography must
increase with patient thickness to maintain compara-
ble image noise, approximately doubling for each
additional 4 to 5 cm of patient thickness. One CT
SPR image obtained at 300 mA delivered an effective
skin exposure level and effective dose of 330 mR
(85.1 mC/kg) and 0.54 mSv [17]. One abdominal-
pelvic CT scan delivers an effective skin exposure
level of 2500 mR (645 mC/kg) and effective dose of
approximately 11 mSv. Estimated skin doses and
Fig. 3 (continued).
effective dose for combined CT and projection urog-
raphy are considered to be less than what a separate
CT study and conventional intravenous urography
with nephrotomograms deliver.
Excretory-phase enhanced CT with multiplanar
reformation and three-dimensional
reconstruction imaging
This approach relies exclusively on the acquisition
of unenhanced and enhanced CT scans of the collect-
ing systems including the essential acquisition of
thin-section helical CT scans obtained during the
excretory phase of enhancement. Multiplanar refor-
mation and three-dimensional reconstruction images
obtained during the excretory enhanced phase are
generated on workstations from axial source images
[2126]. No bowel preparation is necessary for this
type of CT urography examination. The possibility of
aspiration of solid food by vomiting can be avoided,
however, if oral intake is withheld for several hours
before the examination.
In a study using a single-detector helical scanner by
McNicholas et al [21], excretory-phase enhanced CT
scans were obtained with slice thickness of 5 mm, pitch
of 1.5, and slice increment of 2.5 mm. Multidetector
row helical CT scanners allow single breathhold
acquisitions of the abdomen and pelvis with narrow
collimation to achieve high spatial resolution [27].
Several researchers have used multidetector row CT
with slice thickness of 2.5 to 3 mm and slice increment
of 1 to 1.25 mm for CT urography [22,24,25], and
others more recently used slice thickness increment of
1 to 1.25 mm to generate a single volume dataset with
near-isotropic voxels. Multiplanar reformatted and
three-dimensional reconstructed images can be dis-
played with improved spatial resolution in nontrans-
verse planes on workstations [23,26].
Detection of urothelial abnormalities with excre-
tory CT urography requires visualization of the
optimally distended and opacified collecting system
Fig. 3 (continued).
as traditionally seen on intravenous urography. It may
be difficult to obtain a single set of images on which
the collecting systems are completely opacified. Sev-
eral studies have shown that CT acquisition using
abdominal compression improved opacification of
the collecting system compared with CTscans without
compression [21,28]. Caoili et al [23] used two CT
acquisitions of the entire urinary tract during the
excretory phase of enhancement: one with abdominal
compression and the other after release of abdominal
compression. McNicholas et al [21] showed excretory-
phase CT scans with patients in a prone position also
improved opacification of the distal ureters compared
with supine CTscans without abdominal compression.
Alternative techniques for achieving optimal visuali-
zation of the collecting systems include supplemental
use of normal saline infusion and diuretic injection.
McTavish et al [26] reported supplemental infusion
of 250 mL of physiologic saline immediately after
injecting intravenous contrast material significantly
improved opacification of the distal ureters. Nolte-
Ernsting et al [25] reported that intravenous injection
of low-dose diuretics (10 mg of furosemide) before
intravenous contrast injection also permitted less
dense, homogeneous opacification of the collecting
systems compared with supplemental infusion of
300 mL of normal saline. Because CT has contrast
resolution superior to conventional radiography, dilu-
tion of the contrast material does not substantially
affect perception of contrast enhancement of the
collecting systems [25,26] and may minimize poten-
tial beam-hardening artifacts associated with dense
contrast material in the intrarenal collecting system
[25]. An alternative CT urographic approach consists
of two CT acquisitions: unenhanced and enhanced
[22,24]. Following initial noncontrast CT, two admin-
istrations of a split dose of intravenous contrast
material are given, and both nephrographic and ex-
cretory-phase images are acquired during the second
acquisition [24]. This method, however, requires two
contrast injections and two CTexaminations separated
by 15 minutes. Chow and Sommer [22] reported
obtaining combined nephrographic- and excretory-
phase enhanced CTscans of the kidneys and proximal
ureters with abdominal compression by scanning 90
seconds after the second dose of a two-phase injection
of iodinated contrast material temporally separated by
2 minutes. Immediately after release of compression,
the excretory-phase enhanced CT scan is continued to
cover the distal ureters and bladder.
Assessment of axial CT images (source images),
which are usually displayed with wide window set-
tings similar to the bone window setting, remains
essential for accurate diagnosis, and the large amount
of data to be evaluated requires interactive viewing
on a workstation. Multiplanar reformation images
provide orthogonal coronal or oblique (en face)
planes, which help to define the location and extent
of the lesions shown on axial CT images (see
Figs. 2D, 3E). Maximum intensity projection (MIP),
average intensity projection, and perspective volume
rendering reconstructed images at thin (5 to 20 mm)
and thick (35 to 60 mm) slabs can be generated from
the volume data. Thick slab three-dimensional recon-
structed images provide an overview of the collecting
systems and mimic conventional intravenous uro-
grams, but assessment of urothelial wall thickness is
difficult (see Figs. 2G, 3F, 3G). Thin slab recon-
structed images have the advantage of covering a
considerably longer range than standard multiplanar
reformations and have the ability to demonstrate
small filling defects, which may be obscured by
surrounding contrast in the collecting system with
thick slab reconstruction (see Fig. 2F). Curved planar
reformation provides a single image to outline the
course of ureterectasis to the point where an obstruct-
ing process, such as a calculus or tumor, is present
(see Fig. 1C) [22]. Large data sets with 400 to 800
axial source images are common and need to be
reviewed efficiently at a workstation.
In a study of 65 patients who underwent multi-
detector row CT urography for urologic indications,
CT urography detected 15 of 16 urothelial carcino-
mas and many other urinary tract abnormalities [23].
The single missed lesion (transitional cell carcinoma
at the bladder base) could be identified in retrospect. In
the same series, three lesions of ureteral transitional
cell carcinomas appeared as circumferential ureteral
thickening on CTurography. Acase of ureteritis had an
indistinguishable appearance. In a study of 57 patients
with hematuria and unexplained hydronephrosis who
were studied with both multidetector row CT urogra-
phy and retrograde pyelography after nondiagnostic
intravenous urograms or ultrasonograms, there were
38 intrinsic urothelial lesions including 15 transitional
cell carcinomas, 13 urinary stones, 5 cases of uretero-
pelvic junction obstruction, 3 cases of ureteral stric-
ture, and 2 bladder polypoid lesions [29]. Of the
38 intrinsic lesions, CT urography detected 37 lesions
with sensitivity of 97%, whereas retrograde pyelo-
grams detected 31 lesions (82%). Abladder tumor was
missed on CT because the bladder was obscured by
beam hardening artifacts from bilateral hip prostheses.
In a study by McTavish et al [26], estimated skin
doses from CT urography using the three-phase CT
scan protocol were similar to standard intravenous
urography, whereas the total effective doses from CT
urography were approximately two times higher than
intravenous urography. In a study by Caoili et al [23],
estimated effective doses from a four-phase CT
urography protocol ranged 25 to 30 mSv. Estimated
effective doses from abdominal-pelvic CT and con-
ventional intravenous urography with nephroto-
mography were 10 to 15 mSv and 5 to 6 mSv,
respectively. The researchers concluded that multi-
phase CT urography exposes a patient to an amount
of radiation similar to what is experienced during a
combination of standard intravenous urography and
CT of the abdomen and pelvis. Because of the higher
radiation dose, this type of CT urography may be
indicated for the evaluation of hematuria only in
patients with a high risk of malignancy. Continued
efforts are needed to reduce radiation exposure.
CT urography takes longer than a standard ab-
dominal-pelvic CT and requires more input and effort
from both the technologist and the physician [14]. At
the authors institution, CT urography (combined CT
and intravenous urography) is charged as a combina-
tion of CT of the abdomen with and without intrave-
nous contrast, CT of the pelvis with intravenous
contrast, and a limited intravenous urogram. Three-
dimensional reconstruction is more labor intensive
and can result in an additional charge.
MR urography
MR urography can be performed with heavily
T2-weighted pulse sequences similar to MR cholan-
giopancreatography, T1-weighted pulse sequences
following intravenous gadolinium contrast agent sim-
ilar to MR angiography, or a combination of the two.
Many studies have documented the ability of MR
urography to detect urinary tract abnormalities, such
as urinary tract dilatation, ureteric obstruction, dupli-
cated renal collecting systems, urinary stones, and
urothelial tumors. The sensitivity of renal parenchy-
mal MR imaging with intravenous gadolinium con-
trast for assessing renal masses and abnormalities of
the nephrogram is considered to be similar to that of
CT. Combining renal MR imaging and MR urogra-
phy can serve as a comprehensive imaging of the
renal parenchyma, collecting systems, and bladder in
patients who cannot go to routine radiographic stud-
ies, such as pregnant or pediatric patients, patients
with a severe allergy to iodinated contrast media, or
patients with impaired renal function.
Heavily T2-weighted MR urography
The fundamental concept underlying this tech-
nique is that simple fluids, such as urine, have very
long T2 relaxation times. Heavily T2-weighted pulse
sequences generate images with high signal intensity
from static fluid in the collecting systems, whereas
the signal intensity from parenchymal tissues with
shorter T2 relaxation times is suppressed. Early
attempts at MR urography used relaxation enhance-
ment and fast spin echo sequences (GE Medical
Systems; or turbo spin echo, Siemens Medical Sys-
tems, Iselin, NJ, and Philips Medical Systems, Best,
The Netherlands), but these were limited to some
extent by the long acquisition times and concomitant
respiratory motion artifacts [6,30]. The most common
T2-weighted technique currently in use is the single-
shot fast spin echo sequence (SSFSE, GE Medical
Systems; and half-Fourier acquisition single-shot tur-
bo spin echo, Siemens Medical Systems) (Figs. 46).
This is a variant of fast spin echo in which all of the
180-degree radiofrequency refocusing pulses needed
to generate an image are acquired after a single
90-degree excitation. Generally, a half-Fourier acqui-
sition is used so that half of the usual number of phase-
encoded steps is required [31,32]. This technique
generates images sequentially within 1 to 2 seconds
with excellent in-plane spatial resolution. Multiple
thin-section images can be acquired within a breath-
hold, thereby eliminating respiratory artifact. Thick
section projection images are also useful for global
evaluation of the urinary tract. Image contrast depends
primarily on the value of TE: as TE is increased,
background suppression increases, but there is a de-
cline in signal-to-noise ratio (SNR).
Other new pulse sequences may have potential
in MR urography. Steady-state free precession se-
quences (fast imaging using steady-state acquisition
[FIESTA, GE Medical Systems], fast imaging with
steady-state precession [TrueFISP, Siemens Medical
Systems], balanced fast field echo [Philips Medical
Systems]) are steady-state coherent gradient echo
pulse sequences that refocus the transverse magneti-
zation between the excitation pulse and gradient
echo acquisition to minimize substantially dephasing
effects of transverse magnetization and allow acqui-
sition of high SNR images at very short TRs. Steady-
state free precession sequences can be performed using
either two- or three-dimensional acquisitions. Signal
intensity of steady-state free precession sequences is
independent of TR and related to T2/T1, which accen-
tuates signal intensity of fluid. Another sequence is a
three-dimensional fast recovery fast spin echo (GE
Medical Systems) pulse sequence. The fast recovery
feature uses an additional radiofrequency pulse at
the end of each TR to refocus the residual trans-
verse magnetization into the z axis, allowing shorter
TRs while still enhancing the signal intensity of
static fluid and providing high-resolution heavily
T2-weighted images with shorter acquisition time
compared with three-dimensional fast spin echo
imaging. In general, three-dimensional sequences
offer fundamental advantages over two-dimensional
acquisitions: SNR is usually higher, through-plane
spatial resolution is improved, and there is less oppor-
tunity for spatial misregistration artifacts caused by
breathholding discrepancies.
These heavily T2-weighted MR urography tech-
niques allow for excellent visualization of the urinary
tract and are particularly useful in patients with
dilated collecting systems. T2-weighted MR urogra-
phy is suitable for the detection and localization of
ureterectasis, especially in the case of markedly
impaired renal function, where contrast-enhanced
urography is limited by impaired excretion of con-
trast. If distention of the collecting system is inade-
quate, it is difficult completely to visualize anatomic
detail. Adequate hydration is essential for diagnostic
MR urography. In many patients, particularly with
nonobstructed, nondilated collecting systems, the
addition of diuretics (eg, furosemide) is critical for
adequate visualization of the collecting system and
ureters (see Figs. 4B, 5C) [3335].
Heavily T2-weighted MR urograms can be
obtained as single thick (5 to 9 cm) slab projection
images or MIP views generated from multiple thin
(5 mm or less) section images. Single thick slab
projection imaging with a large field of view obtained
in coronal and both oblique coronal projections
provides a quick survey of the upper tract without
requiring any postprocessing. The multislice method
is more time-consuming, but the acquisition of thin
single slices reduces partial-volume averaging and
offers a better opportunity to detect small intraluminal
filling defects, which may be obscured by surround-
ing urine, particularly in the dilated system on a
single thick slab projection MR urogram.
Visualization of the urinary tract may be degraded
by superimposition of fluid-filled extraurinary struc-
tures (eg, bowel loops, common bile duct, gallblad-
der); this is most problematic with thick-slice heavily
T2-weighted MR urograms. Thin-slice images are not
affected by superimposed extraurinary fluid-filled
structures. The image quality of three-dimensional
Fig. 4. Normal T2-weighted MR urography with and without furosemide. (A) Oblique coronal SSFSE (TR of 2046 milliseconds,
TE of 974 milliseconds, 36 36 cm field of view, matrix of 256 256, 0.5 number of excitation [NEX], 5-cm slice thickness,
2-second acquisition time) demonstrates an extrarenal pelvis ( p) on the right. d = duodenum; s = cerebrospinal fluid; b = bladder.
(B) Repeat SSFSE image 10 minutes after intravenous administration of furosemide (20 mg) reveals distention of the right renal
collecting system ( p), ureter (u), and bladder (b). d= duodenum; s = cerebrospinal fluid; b = bladder.
MIP reconstructions can be improved by manually
removing extraurinary fluid-containing structures
from the volume.
A significant limitation of heavily T2-weighted
MR urography is that it provides relatively little
functional information [36]. It can be difficult at
times to distinguish between obstructive and non-
obstructive urinary dilatation. One clue often noted in
cases of acute obstruction is the presence of perirenal
edema, seen as high signal intensity on T2-weighted
images [37].
Gadolinium-enhanced T1-weighted MR urography
Gadolinium-enhanced T1-weighted three-dimen-
sional spoiled gradient echo imaging of the urinary
tract (GE Medical Systems; fast low-angle shot,
Siemens Medical Systems; fast-field echo, Philips
Medical Systems) [34,38] is an alternative method
of MR urography and is also referred to as contrast-
enhanced excretory MR urography (see Fig. 5D;
Fig. 7). Three-dimensional sequences generate low
contrast images of parenchymal and background tis-
sue, an effect accentuated as the flip angle increases.
Image contrast is provided by the T1-shortening
properties of gadolinium as it is excreted into the
urinary collecting systems. Additional background
suppression can be provided by the use of spectral
fat saturation. An alternative, little used technique is to
obtain both precontrast and postcontrast three-dimen-
sional acquisitions and then subtract the mask from
the postcontrast data set. This technique provides
Fig. 5. Normal T2-weighted MR urography and gadolinium-enhanced T1-weighted MR urography. (A) Intravenous urogram
demonstrates normal renal collecting systems. (B, C) Heavily T2-weighted SSFSE image (TR of 2046 milliseconds, TE of
974 milliseconds, 5-cm slice thickness, 36 36 cm field of view, NEX of 0.5, matrix of 256 256, 2-second acquisition time)
after intravenous injection of furosemide (C) demonstrates improved distention of the intrarenal collecting system when
compared with heavily T2-weighted SSFSE image before furosemide injection (B). (D) Gadolinium-enhanced three-dimensional
SPGR (TR of 6.4 ms, TE of 1.4 ms, flip angle of 45 degrees, 26 19.5 cm field of view, 1.6-mm slice thickness, 0.8-mm
overlap, 33-s acquisition time, 256 160 1 NEX) demonstrates improved visualization of the renal collecting systems.
excellent background suppression but is limited by the
potential for misregistration artifacts. Acquisition of
contrast-enhanced MR urography during a breathhold
is extremely important to eliminate motion artifact
caused by respiratory excursion of the kidneys
[38,39]. Respiratory-gated imaging is an alternative
when respiratory suspension is difficult (eg, pediatric
patients) [40,41]. Images are typically acquired
5 to 8 minutes after intravenous administration of
gadolinium contrast agent. Contrast-enhanced three-
dimensional MR urography can be improved by using
a diuretic (eg, furosemide) to provide additional
distention and improved visualization of the collecting
system and ureters (see Fig. 5D) [42]. Diuretic is
useful not only to distend the collecting system but
also optimally to dilute the concentration of gado-
linium in the urinary tract, which helps avoid signal
loss caused by T2* effects associated with concen-
trated gadolinium in urine. With thick (35 to 50 mm)
section T1-weighted two-dimensional spoiled gra-
dient sequences, contrast-enhanced MR urography
provides an overview of the collecting system includ-
ing the intrarenal collecting system [38]. Gadolinium-
enhanced T1-weighted MR urograms can provide
gross assessment of renal function. Suboptimal opa-
cification of the urinary tract (eg, markedly impaired
renal function and high-grade urinary obstruction) can
limit the value of this technique for morphologic
assessment. MIP images are generated from excreto-
ry-phase enhanced three-dimensional spoiled gradient
images. Source images are essential to detect subtle
abnormalities of the urinary tract, such as small intra-
luminal filling defects that may be obscured by
opacified urine on MIP images.
A major limitation of MR urography is the detec-
tion of urinary calculi, which generally appear as
filling defects or signal voids on both heavily T2-
weighted and contrast-enhanced three-dimensional
spoiled gradient images. Jung et al [43] investigated
82 patients with ureteric obstruction shown or sus-
pected at intravenous urography with heavily T2-
weighted and gadolinium-enhanced T1-weighted MR
urograms. Of 72 patients with ureteral stones, intra-
venous urography and MR urography correctly di-
agnosed 49 and 64, respectively. Of eight patients
with ureteric tumors, intravenous urography and MR
Fig. 6. Papillary necrosis in a 45-year-old woman with sickle cell trait, who presented with asymptomatic microhematuria.
(A) Intravenous urogram obtained 10 minutes after intravenous contrast administration demonstrates multiple areas of contrast
pooling in the papillary regions of the left kidney adjacent to calyces (arrows). (B) Heavily T2-weighted SSFSE (TR of
2046 milliseconds, TE of 887 milliseconds, field of view of 16 26 cm, matrix of 256 256, NEX of 0.5, 5-cm slice thick,
2-second acquisition time) using torso phase array coil 10 minutes following furosemide injection with ureteral compression
demonstrates paracaliceal papillary cavities (arrows).
urography correctly diagnosed three and seven, re-
spectively. One of the ureteric tumors was misdiag-
nosed as a stone by MR urography, because there
was no appreciable contrast enhancement identified.
The main reason for the failure of intravenous
urography was most often the absence of contrast
medium excretion. Dilatation of the urinary tract
facilitated visualization of an intrinsic or extrinsic
obstructing lesion with MR urography. In a recent
study of 49 patients with acute flank pain who were
studied by unenhanced CT, MR urography, and
intravenous urography, ureteral stones were present
in 32 patients [39]. When a complete or partial filling
defect within the urinary tract on both heavily T2-
weighted and gadolinium-enhanced T1-weighted MR
urographic sequences was presumed to be a stone,
the sensitivity and specificity of MR urography was
94% to 100%, and 100% in diagnosing ureteral
stones. Perirenal edema shown as high signal inten-
sity on T2-weighted images was a useful secondary
sign in predicting acute ureteric obstruction. The MR
imaging findings of a nonenhancing filling defect in
the ureter are not specific for a ureteral stone,
however, and may represent blood clot, gas, fungus
ball, and sloughed papilla. Furthermore, it is quite
difficult to visualize small nonobstructive ureteral
calculi and small caliceal renal calculi at MR urog-
raphy with current techniques. On occasion, the
distinction of ureteral stone from vascular impression
and physiologic peristalsis of the ureter may be
problematic. Because urinary stones are not directly
visualized at MR urography, MR urography can be
combined with unenhanced CT to assess for calculi
in patients with hematuria.
Another limitation of MR urography is its rela-
tively poor spatial resolution [36]. Current MR urog-
raphy techniques do not provide visualization of
anatomic detail of the calyces, infundibula, and
ureters equivalent to intravenous urography or CT
urography. It is possible that subtle urothelial abnor-
malities, such as small malignancies, may be unde-
tected with MR urography.
MR urography is, however, an evolving technique
that offers great promise in its ability to provide both
anatomic and functional information. The tradeoffs
between acquisition time, SNR, and spatial resolution
will be alleviated to some extent by the introduction
of parallel imaging techniques to increase acquisition
speed, improved phased-array coil design, new and
refined pulse sequences, and the availability of high-
field (3 T) imaging systems to increase SNR. The
unique ability of MR imaging to provide quantitative
functional information, such as blood flow, perfusion,
and glomerular filtration rate, in addition to anatomic
characterization of the parenchyma and collecting
system could lead to a single comprehensive diag-
nostic study [41,44].
Summary
CT urography and MR urography are an evolving
concept and developing technique. As the technology
matures, CT urography will combine the ultimate
diagnostic capabilities of intravenous urography and
CT. In the near future, many intravenous urograms
will be replaced by CT urography to evaluate patients
with hematuria and other genitourinary conditions.
MR urography currently serves as an alternative
imaging technique to intravenous urography and
CT urography for children and pregnant women
and for patients with contraindications to iodinated
contrast media.
Fig. 7. Hydronephrosis in a renal transplant. Gadolinium-
enhanced three-dimensional SPGR MIP image demonstrates
pyelocaliectasis and ureterectasis of the transplanted kidney
with a short segment of kinking of the distal ureter (arrow)
at the insertion into the native bladder (b).
Acknowledgments
The authors thank Andrew J. LeRoy, MD, and
Robert R. Hattery, MD, for their editorial assistance
and Kathryn A. Herman for assistance with manu-
script preparation.
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Renal imaging with ultrasound contrast: current status
Michelle L. Robbin, MD
a,
*
, Mark E. Lockhart, MD, MPH
a
,
Richard G. Barr, PhD, MD
b
a
Department of Radiology, University of Alabama at Birmingham, 619 19th Street South, JTN363,
Birmingham, AL 352496830, USA
b
Department of Radiology, St. Elizabeths Health Center, 1044 Belmont Avenue, Youngstown, OH 445011790, USA
The use of ultrasound contrast agents (UCAs) in
the kidney has great promise, but has been less com-
pletely studied than in the heart and liver [1,2]. In part,
this is because there is less ambiguity regarding the
cause and treatment of renal masses as compared with
liver masses. Another major reason why renal contrast
ultrasound (US) has lagged heart and liver applications
is that multiple competing modalities exist that per-
form well in such areas as renal artery stenosis and
renal trauma. There are several clinical scenarios,
however, in which renal US contrast imaging may
become the low-cost noninvasive modality of choice:
the indeterminate renal lesion, complex cyst evalua-
tion, and the evaluation of pyelonephritis.
The status of the UCAs currently available for
clinical and investigative use is reviewed. A brief in-
troduction to the microbubble-specific US techniques
useful in renal evaluation is given. Current literature
and experience with the evaluation of a large number
of renal abnormalities are then presented in a problem-
based format.
US contrast agents
Current UCAs consist of intravenously injected
microbubbles. These microbubbles substantially in-
crease the number of reflectors in the vascular space,
dramatically increasing backscatter in vessels. The
first microbubbles used clinically were created from
saline for echocardiography of the aortic root [3].
Further research led to intravenously injected micro-
bubbles that were generally large and were trapped by
the pulmonary capillary bed. Early contrast attempts
thus yielded substantial enhancement in only the right
atrium and ventricle. The room air microbubbles
created were short lived because they lacked a shell.
A shell provides both stability and a relative barrier to
limit the diffusion of the gas within the microbubble
into the surrounding plasma.
The next innovations were to control the size of
the microbubble to less than 7 mm to traverse the
pulmonary circulation, and to use an inert gas for the
microbubble rather than room air. The use of an inert
gas not readily soluble in blood plasma increased the
longevity of the microbubble, called persistence. The
addition of various microbubble shell compositions to
coat and further stabilize the microbubble achieved
persistence in the peripheral circulation on the order
of several minutes or more [4].
Clinically useful microbubbles must be strong
enough to withstand passage through the lungs,
capillaries, and exposure to the pressures generated
in the left ventricle. The ideal UCA should also be
injectable intravenously, easy to use, and without
significant side effects. In particular, it should not
be nephrotoxic, so as to be a substitute contrast agent
for patients with elevated creatinine and those allergic
to iodine-based CT contrast agents. In general, these
UCAs remain within the intravascular space in the
kidney, and are not excreted into the collecting
system, in contradistinction to CT contrast agents.
Although CT is extremely useful in radiologic
imaging overall, few modalities can compete with
US in real-time imaging of the heart. The development
doi:10.1016/S0033-8389(03)00070-8
E-mail address: mrobbin@uabmc.edu (M.L. Robbin).
Radiol Clin N Am 41 (2003) 963978
of UCAs was initially aimed at cardiac imaging.
Table 1 lists UCAs that have been approved in at least
one country or geographic area as of this writing
(March 2003). Optison, Definity, and Imagent are
the three Food and Drug Administration (FDA)
approved UCAs in use in the United States. These
agents are approved for use in patients with suboptimal
echocardiograms, to opacify the left ventricular cham-
ber, and to improve the delineation of the left ventricu-
lar endocardial border.
There are currently no FDA-approved UCAs for
noncardiac applications in the United States. Many
US laboratories have been performing evaluations of
the kidney and liver in clinical trials in multiple
countries. The authors and others have been success-
fully applying this technology to solve relevant
clinical problems primarily in the liver and kidney,
using off-label UCAs that are FDA-approved for
cardiac imaging. Widespread acceptance and use of
UCAs in the United States is not likely to occur until
FDA approval for radiologic indications is achieved,
and adequate drug reimbursement by insurance com-
panies occurs.
Microbubble-specific imaging techniques
Early on, the use of UCAs tended to focus on the
microbubble as a rescue agent, to be used only in an
otherwise failed US examination. These initial appli-
cations were primarily performed with color and
power Doppler. Post-US contrast evaluation con-
sisted of analysis of discrete vessels, determining if
US contrast increased ones ability to detect smaller
or deeper vessels in a renal or liver lesion [5] or
increase the success rate of vessel visualization, such
as the renal artery [6,7]. Although impressive results
were obtained in visualizing smaller vessels and
deeper macrovasculature with respect to conventional
US, contrast agents could not be detected in the
microcirculation of organs, such as the liver and
kidney [8].
An imaging revolution occurred with the appli-
cation of harmonic imaging techniques to contrast
agents [9]. Harmonic imaging is performed in gray
scale instead of color Doppler, with the advantages of
the increased spatial and temporal resolution seen in
gray-scale imaging. Harmonic imaging takes advan-
tage of the fact that microbubbles vibrate when
insonated with the alternating positive and negative
pressures of the sinusoidal sound waves [8]. If ex-
posed to sufficient energy in the incoming US signal,
microbubbles exhibit nonlinear behavior, because
they can expand much more than they can contract.
Fortunately, the resonant frequency of microbubbles
small enough to traverse the pulmonary and capillary
circulations (< 7 mm) falls within the diagnostic range
of US, from 1 to 10 MHz [10]. The harmonic portions
of the image are further separated from the fundamen-
tal (nonharmonic) information by various techniques
that involve US phase or pulse manipulation.
Multiple pulses that vary in either pulse direction
or phase are sent down the same or adjacent scan
lines, depending on the manufacturer. An example of
one method is as follows: a pulse is sent down a
single scan line. Next, the exact opposite pulse is sent
down the same scan line. Returning echoes from the
insonated tissues, which behave linearly, cancel out
when added at the scanner. Returning echoes from the
nonlinear microbubble interactions do not cancel
when summed, and give a signal related primarily
to the harmonic signature of the microbubble. This
process results in a substantial increase in the signal-
to-noise ratio of the blood with respect to surrounding
tissue [10].
Interaction of the US beam and microbubble is
dependant on the microbubble gas and shell composi-
tion, in that a fragile bubble shell may take less power
Table 1
Summary of UCA approval by country
Contrast agent Pharmaceutical Location Indications Countries approved
Imagent Alliance Pharmaceutical San Diego, CA Echocardiography United States
SonoVue Bracco Diagnostics Princeton, NJ Echocardiography Europe
Definity Bristol-Myers Squibb North Billerica, MA Echocardiography,
echocardiography of
liver and kidney
United States, Canada
Optison Amersham Health Princeton, NJ Echocardiography United States, Europe, Canada
Levovist Schering Berlin, Germany Echocardiography,
vascular imaging
More than 40 countries in Europe,
Asia (including Japan), Latin
America, Canada, and Australia
M.L. Robbin et al / Radiol Clin N Am 41 (2003) 963978 964
to break. This is a complex problem, because bubbles
that are too stiff may be broken more easily traversing
the pulmonary circulation or capillaries. In general, a
low-power (low mechanical index [MI]) technique
creates a harmonic signature that can be imaged
readily, but has a low incidence of bubble breakage.
Low MI imaging can be used to view arterial
inflow into an organ, such as the kidney. Relative
vascularity can be assessed by the echogenicity of
tumor versus normal adjacent parenchyma. High MI
imaging at higher power insonation (still within FDA
limits) disrupts the microbubbles, and is another
useful technique in US contrast imaging. Once all
the microbubbles are broken in a given portion of
tissue, additional microbubbles are allowed to wash
in over a given time interval. Another high MI pulse
is then performed. This technique allows an assess-
ment of relative parenchymal vascularity over a given
time interval on still images. Such interval delay
images obviate the necessity for the formal compu-
tation of wash in or washout curves, or region-of-
interest comparisons.
Uses of renal US contrast
Renal mass evaluation
Renal cell carcinoma: evaluation
The most common application of UCAs in the
kidney is in renal mass detection and evaluation. Renal
tumors represent 2.6% of newly diagnosed malignan-
cies [11]. Although approximately 2% of autopsies
may detect renal cell carcinoma [12], it is uncertain as
to how many represent clinically significant disease.
The survival for surgically treated stage 1 disease (con-
fined to the kidney) is excellent. When greater than
5 cm diameter, however, only 36% of renal cell car-
cinomas are stage 1, as compared with 63% of smaller
tumors [13]. The previous 5-year survival rate of stage
1 renal cell carcinoma has been 67% to 73% [14,15].
More contemporary survival rates using revised TNM
staging have been 91%, 74%, 67%, and 32% for stage
I, II, III, and IV disease, respectively [16].
Benign lesions, such as oncocytoma, may appear
similar to renal cell carcinoma at imaging. Renal cell
carcinomas, however, make up 90% to 95% of malig-
nant renal neoplasms, and oncocytomas constitute
only about 3% of renal neoplasms [17]. Because there
is no way reliably to distinguish these two entities,
these tumors need to be removed surgically when pos-
sible [18]. Renal cell carcinomas may be less vascular,
hypervascular, or similar in vascularity to adjacent
cortex when imaged with UCAs, as on CT [19].
It can be argued that large solid masses that are
isoechoic or hypoechoic to renal parenchyma do not
need further evaluation with any contrast media.
Invariably, however, these patients have a CT scan
before surgery, to address several important considera-
tions: (1) the presence or absence of tumor extension
into the renal vein, important for surgical planning; (2)
evaluation of the contralateral kidney for synchronous
renal tumor, which occurs in approximately 2% of
patients [20]; (3) staging of the rest of the abdomen,
assessing for metastases, particularly within the liver.
All of these reasons for imaging the patient with
CT before surgery can be accomplished with con-
trast-aided US. A US contrast study may be useful to
increase diagnostic confidence in the diagnosis of
renal cell carcinoma in the incidentally detected solid
renal mass, before any other imaging tests are per-
formed, and before the patient leaves the US labora-
tory. Further study is necessary, however, to compare
the accuracy, sensitivity, and specificity of renal mass
characterization with US contrast with CT.
Renal cell carcinoma: detection
It is a relatively common scenario to have searched
a kidney for tumor at US, only to have a small lesion
found on a subsequent CT. This is because US is less
sensitive in detecting small renal lesions, particularly if
they are noncontour deforming [21]. Jamis-Dow et al
[22] found that CT depicts more renal masses and
smaller renal masses than US. Of lesions that were less
than 1 cm, 24%were missed by CT versus 80%missed
at US. For a lesion size of 2 cm, 5% were missed with
CT and 30% missed at US. When lesions reached a
diameter of 3 cm, 99%were detected with CTand 95%
with US.
Detection of small renal masses with US contrast is
aided by observing an alteration of the normal cortical
thickness and renal pyramid spacing by a mass. The
renal mass depicted in Fig. 1 was not seen on conven-
tional US. Post-US contrast, an obvious large mass
was seen, altering the normal spacing of the renal
pyramids and cortex, and extending into the renal
hilum. US contrast may help to substantially improve
ultrasounds ability to detect small renal masses, par-
ticularly those that are noncontour deforming. It is
uncertain whether US with contrast will be as good in
the detection of the small renal cell carcinoma as CTor
MR imaging. It will, however, likely narrow the gap
reported previously.
Angiomyolipoma
The most common cause for an echogenic renal
mass is an angiomyolipoma (AML). As the spatial
resolution of US, CT, and MR imaging improves,
however, smaller renal tumors are being detected
more frequently. These tumors are often incidentally
found during the growing numbers of examinations
performed for a nonurologic indication [21]. Forman
et al [23] report that 77% of small renal tumors (< 3
cm) were either slightly or markedly hyperechoic,
compared with 32% of the larger tumors.
Demonstration of an anechoic rim and intratu-
moral cysts can aid in the differentiation of renal cell
carcinoma from AML [24,25]. Yamashita et al [24]
hypothesized that the anechoic rim was compressed
surrounding renal tissue. The anechoic areas with
through sound transmission were thought to be cystic
changes in the tumor. Intratumoral cysts and anechoic
rims were only in renal cell carcinomas, and not in
the AMLs. The substantial overlap of the mildly or
very echogenic renal cell carcinoma with the AML,
however, ensures that CT will continue to be per-
formed in all echogenic renal masses. Thin-section
noncontrast CT can identify the presence of intra-
tumoral fat, characteristic of AMLs, which is rarely
seen in renal cell carcinomas [26].
A recent investigation using Levovist did not find
any improvement in diagnostic accuracy in contrast-
aided characterization of the hyperechoic renal mass
over that of conventional US [27]. Power Doppler
was used to characterize vascular patterns, however,
rather than gray-scale contrast imaging. It is interest-
ing to note that a combined noncontrast and contrast
evaluation similar to that performed in CT and MR
imaging is necessary in the evaluation for hyper-
echoic renal tumors. Fig. 2 shows a patient with
multiple AMLs. On gray-scale imaging postcontrast,
Fig. 1. A 40-year-old woman for evaluation of incidental renal lesion on CT. (A) Conventional longitudinal gray-scale ultrasound
image of the right kidney has a normal appearance. (B) Postcontrast high mechanical index (MI) image of the same region shows
a large enhancing central renal mass (arrows). (C) Longitudinal postcontrast low MI image demonstrates the normal pyramid
distribution (arrows), which is disrupted by a vascular renal mass (arrowheads)
these lesions blend in with the adjacent vascular
cortex, effectively obscuring the lesions.
It is possible that the hypervascular nature of
the typical renal cell carcinoma may allow differ-
entiation from an AML using gray-scale imaging.
Fig. 3 demonstrates the typical hypervascular pat-
tern of a renal cell carcinoma that is moderately
hyperechoic to adjacent renal parenchyma on con-
ventional US.
Cystic masses
Renal cysts are common incidental lesions found
at US, CT, and MR imaging performed for other
indications. Simple cysts are benign and have no
malignant potential. Complex cysts vary in their
malignant potential, depending on the number and
thickness of septations, the presence of mural nod-
ules, and peripheral calcification. The degree of
contrast enhancement of the septations and mural
Fig. 2. A 54-year-old woman with diabetes and incidental echogenic renal lesions on ultrasound. (A) Conventional oblique gray-
scale image of the kidney demonstrates multiple echogenic renal angiomyolipomas (arrows). (B) Oblique postcontrast ultrasound
using low mechanical index does not demonstrate the lesions because of increased echogenicity of the surrounding renal
parenchyma. There is focal alteration of the renal contour (arrows), which represents an angiomyolipoma.
Fig. 3. A 37-year-old woman with incidental echogenic renal lesion on conventional ultrasound for epigastric pain.
(A) Conventional longitudinal gray-scale image of the kidney shows a moderately echogenic renal mass (arrows) extending from
the medullary region to the cortex. (B) Postcontrast high mechanical index image of the same region demonstrates enhancement of
the lesion (arrowheads), which is hypervascular relative to the adjacent parenchyma. Pathology confirmed renal cell carcinoma.
nodules is a key factor in determining whether the
lesion needs to be removed surgically or merely
followed [28]. It can be difficult to demonstrate
vessels in a typical solid renal cell carcinoma at
US, despite low-flow settings on current equipment
and the demonstration of substantial vascularity at CT
or MR imaging. Similarly, it is extremely unusual to
detect vessels in mural nodules or septations in a
complex cyst on conventional US, unless the lesion is
obviously a cystic renal cell carcinoma.
Ultrasound contrast has been shown to improve
the sonographic depiction of vascularity within intra-
cystic septations or solid components, using Levovist
and power Doppler [29]. In this small study of
13 patients, if power Doppler signals were found in
any part of the cyst either precontrast or postcontrast
US, the lesion was considered to be malignant. Six
out of the 12 patients who showed no power Doppler
signals on conventional power Doppler had markedly
enhanced power Doppler signals after contrast injec-
tion. One additional patient was classified as a malig-
nant lesion post-Doppler, for a contrast-enhanced
power Doppler US diagnostic accuracy of 77%, as
compared with 46% for contrast-enhanced CT, and
86% for MR imaging.
Gray-scale contrast imaging may improve this
diagnostic accuracy even further, because significant
gray-scale parenchymal enhancement can be seen in
vessels too small to resolve with power Doppler. It is
important to realize, however, that some minimal
septation enhancement may occur. Undoubtedly, a
small amount of septation vascularity is present or
the septation necroses and degenerates. A few small
bubbles of contrast traveling in a septation are unlikely
to represent a malignancy, in the authors opinion.
Even with thin CTslices through a renal tumor, partial
volume average can occur, sufficient to mask relatively
thin but enhancing septations. Significant enhance-
ment of a cyst septation with microbubbles is always
worrisome for tumor, even if the CT is negative or
indeterminate. Significant septation or mural nodule
enhancement, however, is not 100% specific for ma-
lignancy [30].
Finer intracyst detail is commonly seen at US.
Cyst contents typically look more complex at US
than on CT, altering the renal cyst morphologic
classification somewhat from the Bosniak classifica-
tion used with CT. A suggested classification and
work-up scheme for a renal cystic lesion using UCAs
is as follows [1], although extensive clinical valida-
tion is needed:
Type 1: Simple cyst. Benign, with no malignant
potential. No further work-up.
Type 2: Few thin septations or small amount of
peripheral calcification. Small chance of ma-
lignancy. Evaluate cyst enhancement with
UCA. If no enhancement, no further follow-up
Fig. 4. A 74-year-old woman with renal failure and focal renal lesion on noncontrast CT for abdominal fullness. (A) Axial
noncontrast CT of the left kidney shows an atrophic kidney with hyperdense round, exophytic lesion (arrowheads). (B)
Longitudinal postcontrast image of the left kidney demonstrates a well-marginated anechoic structure in the mid-portion,
consistent with simple renal cyst (arrows). Note the small amount of enhancement of the renal parenchyma (calipers) consistent
with the patients renal failure.
is needed. If substantial enhancement seen,
assess with CT. Even if CT is negative for
enhancement, consider US follow-up.
Type 3: Many thin septations or several thicker
septations or small mural nodule. Intermediate
chance of malignancy. Evaluate cyst enhance-
ment with UCA. If no enhancement seen,
assess with CT, then follow with US. If sub-
stantial enhancement is seen, consider sur-
gery. Follow-up is mandatory if surgery is
not performed.
Type 4: Many thick septations, large mural
nodule, or mural nodularity. High chance of
malignancy. Evaluate enhancement with UCA.
If no sonographic enhancement seen, assess
with CT, then follow with US. If substantial
enhancement is seen, consider surgery.
Fig. 4 shows a hyperdense cyst on noncontrast CT
in a patient with progressive renal failure whose
physician was unwilling to give him iodinated con-
trast. A simple cyst was seen at US, with good through
sound transmission. No enhancement was seen with
US contrast (renal cyst type 1). Fig. 5 shows a small
mural nodule with substantial enhancement postcon-
trast (renal cyst type 3). Pathology showed a fibrous
nodule corresponding to the enhancing mural nodule,
without evidence of malignancy. This case illustrates
the fact that not only neoplasms have vascularity, a
source of false-positive examinations also found in
Fig. 5. A 54-year-old woman with abdominal pain. (A) Conventional longitudinal gray-scale image of the lower pole of the kidney
demonstrates a small complex cortical lesion (arrows). (B) No vascularity is identified by power Doppler in the same region
(arrow). (C) Postcontrast high mechanical index image shows an enhancing nodule (arrowheads) within the lesion. On pathology,
fibrosis with hemosiderin-laden macrophages was present within the nodule, but no malignancy was present in the cyst.
both CT and MR imaging. Another renal cyst, type 3,
is shown in Fig. 6, with multiple septations without
flow on conventional color and power Doppler, which
enhanced with US contrast. Fig. 7 shows a cystic renal
mass with little demonstrable power Doppler flow
precontrast, but substantial enhancement on gray scale
postcontrast. This mass is a type 4 renal cyst and is a
neoplasm until proved otherwise.
Pseudotumors
There are several normal variants that can cause
difficulty in the goal of finding small renal cell
carcinomas. A prominent column of Bertin, persistent
fetal lobulation, and a dromedary or splenic hump can
be mistaken for a mass, especially by the inexpe-
rienced examiner. The morphology of the area of the
potential renal mass is important. A prominent col-
umn of Bertin can be distinguished from a mass at
gray-scale US by assessing the cortical thickness with
respect to the renal pyramid. Typically, the renal
pyramid is located more deeply in the renal sinus
than usual, flanked by normal cortex. The surface of
the kidney in a prominent column of Bertin is
typically smooth, rather than bulging as with a renal
cortical mass [31]. The echogenicity of a column
of Bertin pseudotumor may be slightly increased
because of anisotropic effect [31]. Persistent fetal
lobulation refers to surface lobularity without an
alteration in the spacing of renal pyramids, or thick-
ness of the renal cortex.
With US contrast, a gray-scale image is produced
that is similar to the cortical-medullary phase of
contrast at CT, MR imaging, and angiography. The
cortex brightly enhances and appears echogenic. The
pyramids are less echogenic than the cortex, because
they have less blood flow. Visualization of normal-
appearing smoothly branching vessels from the renal
hilum to the periphery is normal, and is a very useful
sign that no mass is present [6]. Findings suspicious
for malignancy in a mass include vessels with an
abnormal course or branching pattern on gray-scale or
power Doppler imaging. Other imaging findings that
raise the suspicion of a malignancy in a mass include
an increase or decrease in vascularity with respect to
adjacent normal cortex. A recent small series of four
patients with renal mass versus pseudotumor was
evaluated with power Doppler US and Levovist.
Three cases of renal pseudotumors (two columns of
Bertin, one persistent fetal lobulation) and one case of
centrally located renal cell carcinoma were diagnosed
at US, and verified with CT or surgery [32].
Ultrasound contrast can be used to assess renal
vascularity, cortical thickness, and pyramid spacing,
and can be of particular usefulness to the inexpe-
rienced examiner when there is a suggestion of a
renal mass. It is likely that after this approach is
validated in a larger number of patients, renal contrast
US will be the technique of choice to exclude a renal
pseudotumor in the course of normal daily practice,
instead of the more costly CT or MR imaging.
Fig. 6. An 80-year-old woman with abdominal pain. (A) Conventional longitudinal gray-scale image of the kidney shows a large
cystic renal lesion with numerous septations, consistent with a Bosniak III lesion (arrows). (B) Postcontrast high mechanical
index image in the same region clearly shows enhancement of the thickened septations (arrowheads) within the cystic mass,
consistent with renal cell carcinoma.
Indeterminate renal masses
The problem of a renal lesion that is too small to
be characterized adequately on CT or MR imaging is
a common one. Another not infrequent clinical prob-
lem is the patient with a renal lesion that enhances
only minimally on CT, below the cutoff for definite
renal enhancement consistent with a renal cell carci-
noma. Pseudoenhancement is a potential cause of a
false-positive CT [33]. It is useful to be able to make
a definitive diagnosis in such patients, rather than
have the patient and physician endure uncertainty,
long follow-ups, and additional costly testing.
In the authors experience with 69 patients with
indeterminate renal masses, additional information
was obtained with an US contrast-enhanced study
in 96% of patients. These included improved conspi-
cuity of the abnormality (51%); improved delineation
of the abnormality (41%); and exclusion of pathology
(28%). Another important finding was an increase in
diagnostic confidence in 64% of cases. The authors
preferred gray-scale low MI imaging techniques in
most cases, often combined with interval-delay high
MI images for best depiction of the abnormality, over
power or color Doppler [34].
Optimal care suggests that the patient leave the US
laboratory with a definitive accurate diagnosis, rather
than undergo uncertainty regarding a possible abnor-
mality, and the additional time and expense of other
modalities. Fig. 8 shows a renal mass that was inde-
terminate on a dedicated CT with and without intra-
venous contrast, with a measured enhancement of
8 HU. A prior CT scan had shown more lesion
enhancement (but still indeterminate), and this lesion
was being followed for interval growth. US with
contrast showed definite enhancement of both septa-
tions and mural nodules, consistent with a renal cell
Fig. 7. A 54-year-old man with renal lesions discovered on chest CT for small pulmonary nodules. (A) Conventional longitudinal
gray-scale image of the kidney (calipers) shows large complex cystic mass (arrows). (B) No vascularity in the lesion is seen on
power Doppler ultrasound (arrows). (C) Postcontrast high mechanical index technique shows multiple areas of irregular
enhancing septations within the cystic lesion (arrowheads). Clear cell renal cell carcinoma was confirmed by pathology.
Fig. 8. A 42-year-old woman with indeterminate lesion on CT performed for abdominal pain. (A) Precontrast CT image of the
kidney has a normal appearance without focal mass. (B) Postcontrast CT of the same region shows a focal lesion (arrows) that is
hypodense relative to the adjacent renal parenchyma. The enhancement of the lesion measured 8 HU (indeterminate for
malignancy). (C) Conventional longitudinal gray-scale ultrasound of the lower renal pole has mild heterogeneity without definite
focal lesion. (D) Focused gray-scale evaluation of the lower pole in transverse plane shows a heterogenous focal renal mass
(calipers). (E) Postcontrast longitudinal low mechanical index image of the same region demonstrates a complex renal lesion
with enhancement of numerous septations and mural nodules (arrowheads), consistent with a renal cell carcinoma.
carcinoma. It is surprising to see this degree of en-
hancement on an US contrast study, and yet have no
change in Hounsfield units on an optimally performed
thin-section CT because of partial volume averaging.
Renal artery stenosis
Renal artery stenosis occurs in approximately 1%
to 2% of hypertensive patients. Although it is a
relatively uncommon cause of hypertension, angio-
plasty or surgery can virtually eliminate the need for
medication to control blood pressure in some patients.
Screening patients so that there is a higher pretest
probability of the disease still leaves a high percentage
of patients with negative angiograms. Angiography
has a small but real morbidity, coupled with the
potentially nephrotoxic effects of iodinated contrast.
Captopril nuclear renography is commonly used;
however, it may miss bilateral disease [35,36]. It is
also not sensitive in those patients with limited renal
function, a common problem in this patient population
[37]. Although there is substantial development in
using CT and MR imaging angiography for renal
artery stenosis detection, there is no completely satis-
factory screening study [3841].
The sonographic detection of renal artery stenosis
could be one of the commonly performed studies in a
sonologists armamentarium were it not for the deep
location of the main renal arteries and the presence of
accessory renal arteries. The deep horizontal course
of the renal arteries under a large amount of bowel
limits the number of main renal arteries that can be
seen in their entirety, especially in obese patients.
UCAs have been used recently to improve visualiza-
tion of the main renal arteries in difficult patients.
Melany et al [7] found that UCAs improved main
renal artery visualization substantially. Two of eight
cases of stenosis were only seen postcontrast.
Interestingly, they also had seven kidneys with
accessory renal arteries whose accessory arteries were
only seen postcontrast [7]. An accessory renal artery
occurs in up to 30% of the population [42], and
theoretically can be the cause for patients hyperten-
sion. Increased ability to detect accessory renal arteries
with UCAs may negate one of the theoretical reasons
that the US examination has never been widely per-
formed. It has been reasoned that there is no point in
using US for stenosis detection because of poor
accessory renal artery detection. A recent article from
Bude et al [43], however, found that the incidence of a
hemodynamically significant stenosis isolated to an
accessory renal artery is very small (1.5%). They con-
cluded that failure to detect accessory renal arteries
should not affect the use of a noninvasive test for
detecting renovascular hypertension.
The use of UCAs to increase the number of
reflectors in the main and intrarenal arteries is an
excellent use of microbubbles. Spectral Doppler gate
placement accuracy and angle correction are im-
proved with better vessel delineation. The ability to
improve the spectral Doppler signal by better vessel
visualization is useful not only in the main renal
artery but also in the segmental intrarenal arteries.
Evaluation of the intrarenal arteries is necessary when
the main renal arteries cannot be visualized in their
entirety [44]. Although there is controversy regarding
which should be studied, the main renal arteries or the
intrarenal arteries, it is usually preferable to directly
visualize the abnormality rather than to infer its pres-
ence from an indirect test.
Ultrasound contrast agents have been found to
increase the number of technically adequate diagnos-
tic examinations of the main renal artery [7]. UCAs
have also been found to improve technical success
and increase diagnostic confidence after renal artery
angioplasty and stenting [45]. A significant difference
in the enhancement curve of kidneys with renal artery
stenosis compared with normal kidneys was found by
Lencioni et al [46]. UCAs also can decrease the time
needed for the examination.
It can be argued that the renal artery stenosis ex-
amination should be performed only after a UCA in-
jection, rather than UCAs used as a rescue agent, after
failure to see the main renal arteries. Undoubtedly,
there are some patients whose main renal arteries
would have been seen well without a UCA. In an ex-
amination whose technical failure rate can reach 20%
[47] even in experienced hands, however, any tool to
increase the accuracy and speed of the examination
should be used routinely, rather than selectively.
Renal perfusion
The lack of a clinically available contrast agent
severely hampers the ability of US to detect changes
in renal perfusion, except in a gross fashion. Often,
only a subtle alteration in renal echotexture is seen at
US despite a substantial renal perfusion abnormality
because of renal infarction, infection, or transplant
rejection. CT, MR imaging, or radionuclide scintig-
raphy is usually performed to assess perfusion.
Infarction
Contrast-enhanced US seems promising in the
detection of decreased renal vascularity from infarcts.
It has been found to be an effective way of depicting
focal renal perfusion defects in the pig and rabbit
[48,49]. Animal studies have been extended to the
human by Yucel et al [50], who demonstrated sub-
stantial improvement in visualization of renal infarcts
over power Doppler US in three patients [50]. This
technique may be a useful front-line study in the
radiologists armamentarium, especially in the patient
with compromised renal function. UCAs also may be
used to image the main renal artery and vein of these
patients, to evaluate for potential extension of either
arterial or venous thrombus. Complete sonographic
imaging of the renal infarct without the added time to
diagnosis, additional expense of other modalities,
and lack of potential nephrotoxicity found with
iodinated contrast agents is attractive, if borne out
in larger studies.
Pyelonephritis
Ultrasound is commonly used as the first moda-
lity for renal evaluation in cases of suspected pyelo-
Fig. 9. A 20-year-old woman with fever and flank pain. (A) Conventional longitudinal gray-scale ultrasound of the kidney
(calipers) demonstrates thickening of the renal cortex in the mid-portion without substantial gray-scale changes. (B) Longitudinal
power Doppler image in the same region shows abnormal hypoperfusion of the renal vasculature in the region of cortical
thickening (arrows). (C) Postcontrast transverse image using low mechanical index technique demonstrates a focal hypoechoic,
or avascular, region in the cortex (arrowheads). (D) Axial CT image of the same region confirms focal hypoenhancement of the
parenchyma (arrows), consistent with pyelonephritis.
nephritis. After appropriate antibiotic treatment, if the
patient is still febrile and has significant flank pain, a
CT is obtained to exclude a drainable renal abscess.
Power Doppler has been shown to be useful in the
detection of perfusion abnormalities associated with
pyelonephritis in children [51,52]. Fewer gray-scale,
color, and power Doppler changes are seen, however,
in the adult with pyelonephritis. This finding is likely
secondary to the increased mass of adults as com-
pared with the average child, despite the increased
penetration and power Doppler sensitivity present in
current equipment. Contrast-enhanced CT may be
necessary to help distinguish between pyelonephritis,
abscess, or infarction [53].
UCAs have been shown to be useful in detecting
changes consistent with infection or scarring in a
porcine model of experimental pyelonephritis [54].
Contrast US may be used both to detect or exclude the
perfusion defects seen with pyelonephritis, and assess
for the presence of a drainable abscess [55]. In the
future, it is doubtful that CTwill be needed for further
assessment, because a repeat US can be performed
readily if the patient fails to respond to therapy. Fig. 9
demonstrates the decrease in regional perfusion seen in
a patient with pyelonephritis, with CT correlation.
Perfusion
Assessment of renal blood flow can be useful in
patients with both acute and chronic renal failure.
Clinically, most interest focuses on the renal trans-
plant rather than the native kidney. Assessment of
blood flow changes in the transplant can be helpful in
sorting among diagnostic possibilities for renal dys-
function, including acute tubular necrosis, acute and
chronic rejection, cyclosporine toxicity, and renal
artery stenosis. Preliminary work has been performed
in a variety of experimental animals and in the human
[5663]. Solving the clinical problem of noninva-
sively determining blood flow volume also may be of
use in other organs, such as the liver.
Trauma
The sonographic detection of renal contusions,
lacerations, and hemorrhage posttrauma is less sensi-
tive than CT [64], in large part because of the lack of a
contrast agent. With a UCA, parenchymal renal injury
detection sensitivity may approach that of CT in the
patient who is not morbidly obese. The use of UCAs
in the sonographic detection of acute parenchymal
injury has been evaluated in the pig, rabbit, and dog
[6567]. The increasing frequency of CT scanners in
emergency departments, however, makes the routine
use of US contrast in the detection of renal parenchy-
mal injury in humans somewhat doubtful. The use of
UCAs may be restricted to those trauma patients with
hematuria who are otherwise asymptomatic.
Intraoperative
There is growing interest in renal-sparing tech-
niques as a result of increased detection of incidental,
clinically silent small renal tumors. Radiofrequency
ablation is being evaluated as an alternative therapy
in renal cell carcinoma patients who are not surgical
candidates, and as a treatment for small incidental
tumors. In this procedure an image-guided radiofre-
quency ablation needle is advanced into the tumor
and electrical energy is used to produce heat to kill
the tumor cells [68]. It is important to ablate the entire
tumor and a margin of surrounding tissue. Contrast-
enhanced US is useful for initial tumor localization,
and to detect residual tumor after ablation [69].
Although CT can be used to guide this procedure,
US has several advantages, including real time needle
placement and multiple scanning planes. The use of
UCAs during the procedure can improve the detec-
tion of residual tumor at the time of the procedure
(RGB, personal communication, 2003). Usually, addi-
tional contrast cannot be given after a CT-guided
radiofrequency ablation because of nephrotoxicity
limitations and residual contrast within the kidney.
This is in contradistinction to US, where small bol-
uses of a UCA can be given multiple times without
consideration of nephrotoxicity.
Summary
The application of UCAs to the kidney is still in its
infancy; however, there are several areas of great
promise. UCAs may replace CT in complex renal cyst
evaluation and follow-up, eliminating the need for
costly CT scans with their attendant potential contrast
nephrotoxicity. This approach may decrease patient
and physician uncertainty and improve diagnostic
confidence. The use of UCAs is likely to be clinically
useful in the evaluation of the indeterminate small
renal mass on CT or MR imaging. Another probable
useful application will be in renal artery stenosis.
Routine application of UCAs may increase the per-
centage of diagnostic examinations, increase diagnos-
tic confidence, and decrease examination times. It also
will likely become the first line of evaluation in
pyelonephritis, and be useful in immediate assessment
of residual tumor after radiofrequency ablation. Of
course, substantial additional work needs to be per-
formed in large groups of patients to prove this
currently optimistic outlook.
Acknowledgments
The authors gratefully acknowledge research
support from Bristol Myers Squibb (North Bellerica,
MA), and equipment and technical support from
Acuson, a Siemens company (Mountain View, CA),
and ATL, Phillips Medical Systems (Bothell, WA).
The authors thank Lisa Nelson, RN, BSN; Cynthia L.
Peterson, BS, RDMS, RVT; Michael Clements, BS,
RDMS, RVT; Carl Abts, RDMS; and Al Hester,
RDMS, RVT for their invaluable assistance in our
ultrasound contrast research programs. The authors
also thank Trish Dobbs for her assistance in manu-
script preparation, and Anthony Zagar for photo-
graphic assistance.
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CT evaluation of urinary lithiasis
GU Radiology Section, Department of Radiology, JT N370, University of Alabama at Birmingham,
619 South 19th Street, Birmingham, AL 35233, USA
Diagnostic imaging has been a key part of the
evaluation of urinary lithiasis nearly since the dis-
covery of the x-ray. The first radiograph of a renal
calculus was obtained within months of Roentgens
report [1]. With the development of intravenous con-
trast agents by Swick in 1929, the intravenous uro-
gram (IVU) became the unquestioned mainstay of
this evaluation (Fig. 1) [2]. In 1985 Pollack in a
monograph entitled Current Status of Excretory Urog-
raphy stated Of the various radiologic studies that
may be used in investigating patients with flank pain
or renal colic, the excretory urogram is the most
expedient. . .its sensitivity. . .makes it invaluable
[2]. It was often stated during the IVU period from
1929 to 1994 that 90% of urinary calculi were
radiopaque, proving the validity of the urogram. It
was never proved, however, that 90% of calculi are
visible on conventional radiographs. Rather, Herring
in 1962 reported that 90% of 10,000 calculi contained
some calcium [3]. In fact, only about 60% of urinary
calculi are visible on radiographs (Fig. 2) [3].
The first report of the use of unenhanced CT for
detection of urinary tract calculi was by Smith et al
[4] in 1994 at the annual meeting of the Radiologic
Society of North America. A spate of publications
ensued, all showing high sensitivity of CT for detec-
tion of renal and ureteral calculi, with no paper since
reporting better accuracy for any other imaging test.
After some initial skepticism, unenhanced CT has
become the standard method for evaluating flank pain
and suspected urinary lithiasis. In a recent case of a
patient suffering a contrast reaction from an IVU, a
malpractice suit was brought claiming unenhanced
CT should have been done [5]. (Note the American
College of Radiology still lists IVU and unenhanced
CT as equivalent in their appropriateness criteria [6].)
Advantages and disadvantages of CT
In the initial reports by Smith et al [4,7] and
subsequent reports, the clear advantage of unen-
hanced CT was its unsurpassed accuracy, Smith
initially reporting 97% sensitivity and 96% speci-
ficity in 292 patients. Fielding et al [8] reported 98%
sensitivity and 100% specificity. Chen and Zagoria
[9] reported 100% sensitivity and 94% specificity.
Smiths initial report in fact used nonspiral CT, but
quickly the use of spiral CT added the advantage of
speed. Niall et al [10] reported sensitivity of 100%
and specificity of 92%, with the mean time of
performance of CT at 4 minutes versus 63 minutes
for IVU. The entire abdomen can be scanned literally
within seconds with current multidetector CT devices
(Figs. 3, 4).
Another advantage of CT is its ability to detect
nongenitourinary (GU) and nonstone disease, which
may be the cause of pain (Fig. 5). Smith et al [7] found
alternate diagnoses in 30 of 210 patients, whereas
Fielding et al [8] reported nonstone GU pathology in
14% and non-GU disease in 11% of 100 patients.
Such abnormalities as appendicitis, diverticulitis, ad-
nexal disease, gallbladder disease, biliary disease, and
unsuspected tumors may be seen. The possibility of
detecting non-GU disease on IVU is nearly nil.
Although initial skeptics believed that the IVU
had an advantage of demonstrating physiologic in-
formation with the degree of delayed excretion
indicating degree of obstruction, numerous investi-
gators have shown that findings on CT allow pre-
doi:10.1016/S0033-8389(03)00067-8
E-mail address: pkenney@uabmc.edu
Radiol Clin N Am 41 (2003) 979999
Fig. 1. Clinical information: right flank pain. (A) Scout radiograph shows small calcification in right pelvis (arrows). (B) Urogram
film with 2.5-hour delay was required to document columning of the ureter to the stone.
Fig. 2. Clinical information: left flank pain. (A) On scout of the initial study, a urogram, no stone was identified. (B) Urogram
(improperly done with compression) failed to identify the stone (in retrospect present over sacrum [arrow]). (C) Scout view for
subsequent CT shows a calcification in left pelvis, where none was before (arrow). (D) Unenhanced CT shows mild left
hydronephrosis. (E) There is left ureterectasis (arrow). ( F) The stone is at left ureterovesicle junction (UVJ).
P.J. Kenney / Radiol Clin N Am 41 (2003) 979999 980
diction of outcome and can direct management. Most
importantly, it has been documented that measure-
ment of stone diameter on CT is accurate, because
stone size is the single most reliable indicator of
stone passage [11].
Potential disadvantages of CT include cost, radia-
tion exposure, and proper patient selection. Although
most practitioners charge for a limited CT, consider-
ably less than the usual CT charge, this usually is
more than the charge for an IVU, perhaps three to
five times greater [12]. One can argue, however, the
greater accuracy and speed of CT justifies somewhat
higher cost. Radiation exposure is an issue. There is
potential for significantly greater radiation exposure
with CT, and the target population is generally young
and has a nonfatal illness.
Indication creep has been reported as a common
problem. In 1997 Fielding et al [13] reported 58% of
her patients with CT for flank pain had urinary
lithiasis. Chen et al [14] reported the initial positive
rate of 49% dropped to 28% when re-evaluated a year
later, whereas the rate of alternate diagnoses rose
from 16% to 49%. One could debate, however,
whether this is truly a problem, because CT has
become recognized as an accurate and efficient means
of diagnosis of many abdominal processes, and is
Fig. 2 (continued).
also now the standard method to seek appendicitis
and acute abdominal other disorders.
Technique
No preparation is necessary, and because no
contrast is used there are virtually no contraindica-
tions to performance of unenhanced CT, but the
possibility of pregnancy must be addressed in
women. The usual method of scanning uses 120 to
140 kilovolt (peak) (kV[p]) with 5-mm collimation
and pitch of 1.5:1. Pitch of 1:1 may be preferable but
is not necessary; small stones may be missed with
pitch of 2 or more. After a scout view, scanning from
just craniad to the kidneys to just below the bladder
base can be done in one or two breathholds in most
patients depending on the CT device. It is advanta-
geous to have a radiologist assess the images before
removing the patient from the scan room. At
the authors institution, about 12% of patients are
administered intravenous contrast, either to document
that opacity definitely lies within the ureter when that
is unclear; to evaluate further some abnormality, such
as a mass or possible pyelonephritis; or to search for
nonstone pathology if no stone is identified in a
patient with somewhat nonspecific symptoms. If the
desire is to visualize the ureter, the contrast dose can
Fig. 3. Clinical information: right flank pain. (A) Unenhanced CT demonstrates marked perinephric stranding (arrowheads), mild
pyelocaliectasis, and dilatation of proximal right ureter (arrow). (B) The stone is shown in the distal right ureter (arrow).
Fig. 4. Clinical information: right abdominal pain. (A) There is mild right perinephric stranding and moderate hydronephrosis.
(B) The dilated right ureter could be followed to a stone (straight arrow); note the normal appendix (curved arrow).
be limited to 50 mL and an appropriate delay (4 to
5 minutes) used before scanning.
Interpretation is both most efficient and probably
most accurate when done electronically and on soft-
copy. If a ureteral calculus is present but not clearly
evident on the scout view, it may be useful to obtain a
conventional abdominal radiograph, particularly if the
stone is larger than 4 to 5 mm or over 300 HU [15].
Interpretation
Identification of a stone within the ureter is the
most specific diagnostic finding (Fig. 6). Scrolling
sequentially through the images on a workstation, the
ureter can be followed from the renal pelvis as it
courses caudally, anterior to the psoas muscle, ini-
tially lateral to the ipsilateral gonadal vein; lower in
the abdomen the gonadal vein crosses the ureter and
the ureter courses medially (Fig. 7). In the pelvis the
ureter usually courses through mid pelvis and then
anteromedially to the trigone. With experience the
ureter can be followed easily to the stone, especially
if the ureter is dilated (normally about 2 to 3 mm). In
some 50% to 77% [16,17] of cases a confirmatory
finding is seen with soft tissue thickening 1 to 2 mm
around the stone (soft tissue rim sign) (Fig. 8),
resulting from edema at the site of stone impaction.
This tends to be seen more often distal than proximal
and with smaller rather than larger stones. The
specificity of the sign has been reported at 92% [16].
One of the more common challenges is confi-
dently distinguishing a true ureteral stone from a
phlebolith, which are most common in the pelvis.
Fig. 5. Clinical information: right lower quadrant pain, not colicky. (A) CT done initially without intravenous contrast shows no
hydronephrosis, mild symmetric bilateral stranding. Note oral contrast administered as symptoms not clearly that of renal colic.
(B) Enhanced images show normal excretion from both kidneys. (C) Inflamed appendix (arrow) demonstrated; appendicitis
confirmed surgically.
This can be most difficult when the ureter is non-
dilated, and is difficult to follow through the pelvis
(Fig. 9). Phleboliths are typically round, whereas
urinary calculi are often slightly angular. Only 0%
to 20% of phleboliths show a soft tissue rim (Fig. 10)
[1618]. Occasionally a phlebolith may have a soft
tissue tail (Fig. 11) extending from one surface as
from a comet (21% [16]), a finding not seen with
ureteral stones [19]. Phleboliths often (but not al-
ways) show a central lucency, whether on scout view
Fig. 6. Clinical information: right flank pain, only few hours duration. (A) Unenhanced CT shows no significant stranding,
questionable hydronephrosis. (B) Proximal right ureter (arrow) is not dilated. (C) The nondilated ureter (straight arrow) can be
followed readily; note gonadal vein (curved arrow). (D) Small stone is present in right ureter (arrow). This was not visible on
plain radiograph. (E) Follow-up CT documents stone no longer present.
or demonstrated with bone windows or histogram,
whereas true calculi are as dense or denser at center
than periphery [20]. Phleboliths in the gonadal vein
may be misread by those not familiar with the usual
anatomic orientation (Fig. 12). If the ureter has an
unusual course, say secondary to surgery, diagnosis
can be difficult. Comparison with prior CT scans can
be helpful because phleboliths remain stable in posi-
tion, whereas calculi tend to move; in the end, it may
be necessary to inject intravenous contrast to deter-
Fig. 7. Clinical information: vague abdominal pain, no hematuria. (A) Normal enhanced CT shows normal proximal ureters
(arrows). (B) Note nondilated ureters (straight arrows) (not yet opacified by contrast) and gonadal veins (curved arrows).
(C) Note contrast-filled ureters in usual position in upper pelvis (arrows). (D) The normal ureters (arrows) course through mid
pelvis. (E) Unenhanced CT in a different patient shows the normal unopacified ureters (arrows) in mid pelvis. ( F) The
unopacified ureters (arrows) can be followed to the UVJ.
mine absolutely if a density lies within the ureter
(see Fig. 12).
A number of signs secondary to the obstruction
can be useful (Fig. 13). In one study, hydronephrosis
was present in 69% with ureteral stones, dilation of
the ureter in 67%, perinephric stranding in 65%, and
periureteral edema in 65% [21]. Swelling of the
affected kidney may also be seen. The sensitivity of
the combination of perinephric stranding and ureteral
dilation alone for diagnosis of ureteral obstruction has
been reported as 99% [22]. Presence of these sec-
ondary signs then can be taken as indicators of high
likelihood that there is a stone such that a very careful
search is made, and that if it is not certain that a
density is located in the ureter, probably in fact it
is ureteral.
There are limitations with use of the secondary
signs. Hydronephrosis can be overcalled because of
an extrarenal pelvis; it is more reliable to assess the
calyces at the poles, rather than the renal pelvis.
Swelling of the kidney is difficult to judge, because
there is variation in kidney size, not always sym-
metric. In general the signs are subjective and it is
difficult to grade severity. Perinephric stranding can
be seen in nonobstructed kidneys for various reasons;
if it is not asymmetric and ipsilateral to the patients
symptoms it may not be significant. One cause of the
perinephric stranding is the physiologic effect of
obstruction on the kidney, resulting in increased
lymphatic flow to relieve the pressure and redirection
from hilar to capsular channels [23,24]. Actual peri-
nephric fluid can be seen because of forniceal rupture
(Fig. 14). The renal edema from obstruction also
causes loss of the hyperdense pyramid (mildly greater
attenuation of medullary pyramid versus cortex com-
monly seen on unenhanced CT especially in dehy-
drated patients) (Fig. 15). This can result in the pale
kidney, where the measured attenuation of the paren-
Fig. 8. Clinical information: right flank pain and microhematuria. (A) Unenhanced CT demonstrates mild right perinephric
stranding and moderate hydronephrosis. (B) Right ureterectasis (arrow) is shown in the pelvis. (C) A slightly irregular-shaped
stone (arrow) with soft tissue rim lies just proximal to UVJ. (D) More inferiorly, a round density with no soft tissue rim is seen,
typical phlebolith.
chyma on the obstructed side is 5 to 14 HU less than
the normal side, an objective finding [25].
A number of factors may dictate the presence and
severity of the secondary signs. It has been shown
that the degree of obstruction as estimated from
urograms correlates well with presence and severity
of secondary signs [26]. It also has been shown,
however, that presence of secondary signs increases
in frequency with greater duration of symptoms [27].
These competing factors may explain the controversy
as to whether likelihood of stone passage can be
predicted based on secondary signs; a few papers
indicate a correlation [28] but most fail to do so
[29,30]. The most consistent findings predicting stone
passage are stone size and location. About 90% of
stones 1 mm do pass, but less than 50% of stones
over 7 mm pass [31]. Stones 5 mm or larger that are
located in the proximal ureter are unlikely to pass
spontaneously, whereas distal stones even if fairly
large most often do pass [30]. In general stones over
6 mm commonly require intervention [29]. From the
urologists perspective, degree of obstruction has
never been a tenet directing management [32]; rather
they are stone size, which statistically predicts pas-
sage, and severity of symptoms, which controls
urgency to intervene. Several studies have docu-
Fig. 9. Clinical information: vague left abdominal pain. (A) Although nondilated, the left ureter (arrow) can be followed into
the pelvis. (B) The ureter (arrow) can be followed further. (C) Followed to the UVJ (arrow), no ureteral stone was identified.
(D) More inferiorly there is a density; because this is inferior to the UVJ, it is a phlebolith and contrast administration is
not necessary.
mented the accuracy of CT estimation of stone size in
the transverse plane (although not craniocaudal)
[11,33].
On routine supine images, it may be difficult to be
certain if a stone has already passed into the bladder,
or remains within the intramural course of the ureter,
which is surprisingly long (see Fig. 14). A stone at
the very distal course at the ureterovesicular junction
may even protrude into the bladder, but is off-center,
whereas a stone in the midline has passed into the
bladder. Taking images in the prone position can
prove the position (Figs. 16, 17)
Even with rather large stones, urologists often
attempt conservative management with hydration
and pain management. After a stone is detected by
unenhanced CT, the question of imaging follow-up
arises. It has been shown that a stone visible on scout
view is visible and can be followed by conventional
radiographs (see Fig. 15). Whenever a radiologist
detects a ureteral calculus on unenhanced CT, know-
ing the location, he or she should review the scout
view. If the stone is visible, that should be indicated
to the clinician. Only 17% to 47% of stones are seen
on CT scout view, however, whereas 48% to 60% are
seen on conventional film screen radiograph (Fig. 18)
[34]. Some have attempted to optimize the scout
view, but still the conventional film is more sensitive.
To some degree the visibility relates to size and
composition [35]. Nearly all calculi over 5 mm and
those over 300 HU are visible on radiographs [15].
Stones not seen on scout view and very small with
attenuation less than 200 may need to be followed
with CT.
Although nearly all urinary calculi are detected
with properly done unenhanced CT, several reports
show that stones formed as concretions of crystals of
protease inhibitors (eg, indinavir) are nonopaque
even on CT [36,37]. Given the poor solubility of
these drugs, and the relatively high incidence of stone
Fig. 10. Clinical information: left flank pain, microhematuria. (A) Unenhanced CT demonstrates mild left perinephric stranding
and moderate hydronephrosis; the left ureter was dilated. (B) The left ureter could be followed to a small stone in pelvis, with soft
tissue rim (straight arrow). Note two adjacent phleboliths with no rim (curved arrow).
Fig. 11. Clinical information: left flank pain. Unenhanced CT
demonstrates phlebolith with comet tail sign (arrow); left
ureteral stone was demonstrated in proximal ureter.
formation [37,38], a presumed diagnosis may be
made in patients taking this medication based on
symptoms and demonstration of secondary signs
even if no stone is visualized.
A more serious potential problem with the in-
creasing use of unenhanced CT is the limitation in
diagnosing certain disorders, which may be found
either as an incidental finding, or perhaps as a cause
of presenting symptoms. Many lesions cannot be
detected readily without use of intravenous or gastro-
intestinal contrast, including renal tumors [39]; pyelo-
nephritis; renal infarct (Figs. 1921); and non-GU
disease, such as liver tumors. Although this is poten-
tially more likely with poor patient selection, some-
times renal colic can result from passage of clot
caused by a renal lesion, and the patient may present
with typical obstructive symptoms. Sometimes there
is subtle evidence on unenhanced CT images, such as
a focal bulge of the kidney or perinephric stranding
without a stone. The radiologist must be aware of the
limitations and in the appropriate situation, after
discussion with the referring physician, may need to
extend the examination or recommend further evalua-
tion at a later date.
Radiation issues
Although it is generally believed that CT causes
more radiation exposure than IVU, the relative risk
depends on the technique of each examination. Some
have reported nearly equal doses from CT and IVU
[40], whereas others claim CT overall causes as much
increased risk of cancer in the population as cigarette
smoking [41]. Morin et al [42] reported CTwith 5-mm
collimation, pitch of 1.5:1, and 120 kV(p) resulted in a
0.0036-Gy uterine dose versus 0.0015 Gy for IVU.
Denton et al [43], however, reported exposure of CTas
4.7 mSv versus 1.5 for IVU, but based on a three-film
IVU. The authors departments standard IVU has
included a scout kidney, ureter, and bladder; renal
tomogram and renal cone down; three postcontrast
tomograms; anteroposterior and oblique kidney, ure-
ter, and bladder; and pelvis prevoid and postvoid,
Fig. 12. Clinical information: vague right abdominal pain. (A) Unenhanced CT shows no secondary signs about right
kidney. (B) Note density in retroperitoneum (straight arrow) with soft tissue structure immediately posterior to it (curved
arrow). (C) Contrast was administered for documentation; note the now enhanced ureter (arrow) is posterior to the gonadal
vein phlebolith.
providing considerably more radiation. Regarding
CT, the exact dose depends on technique; reduced
milliampere seconds (MAS) allow detection of most
stones with lesser radiation [44], but performing
multiple series, such as precontrast and postcontrast,
or rescanning with thinner collimation significantly
increases dose.
In practice, widespread use of unenhanced CT for
diagnosis of urinary lithiasis increases radiation expo-
sure, probably more on the order of two to three times
greater for the individual patient rather than five
to six times. It should be recognized, however, that
the population of concern is relatively young and
suffering from a nonmalignant disease, and every
attempt should be made to limit dose and also
perform CT only for solid clinical indications. It
remains controversial how a pregnant patient with
suspected urolithiasis should be examined: limited
urogram or noncontrast CT. At the authors institu-
tion, the advantage of definitive, rapid diagnosis is
believed to outweigh slightly greater radiation expo-
sure (Fig. 22). The radiation exposure is limited by
performing a single test slice at the thickest portion
of the patients abdomen with reduced dose (80 to
100 mA, maintaining kV 140), and assessed by the
radiologist for quality. The examination is then done
with the lowest dose that provides adequate quality in
the individual patient, with every attempt to perform
only a single pass.
Alternatives
Partly because of concerns over cost and espe-
cially radiation exposure, a number of studies have
been published evaluating the use of sonography or
sonography combined with conventional radiography
versus unenhanced CT [4548]. These have docu-
mented the much lower sensitivity of sonographic
techniques (44%, 61%, 77%, and 24%) compared
with sensitivity of CT of 92% to 96%. In addition CT
is performed and interpreted more rapidly, and allows
Fig. 13. Clinical information: acute left flank pain 3 hours duration. (A) Note marked left perinephric stranding, and caliectasis at
upper pole (arrow). (B) The pelvis is dilated; because of the peripheral caliectasis, this is not merely extrarenal pelvis. (C) There
is left ureterectasis with periureteral stranding (arrow). (D) Left ureteral stone (arrow) is shown, with no rim.
Fig. 14. Clinical information: severe right flank pain several hours duration. (A) Unenhanced CT shows bilateral renal calculi
with fluid anterior to right kidney (arrow). (B) Fluid is also seen more inferiorly in retroperitoneum (arrow). (C) A stone is seen
possibly within bladder, but to right of midline. (D) Contrast was administered; note the stone lies at the UVJ, within intramural
course of ureter (arrow). (E) Delayed image shows extravasation of contrast indicating the fluid collection is urine.
for diagnosis of other abdominal disorders, particu-
larly gastrointestinal tract. Some investigators have
suggested the use of MR imaging, which can detect
dilatation and is especially sensitive to secondary
signs [49]. Although this avoids radiation exposure,
it does not reduce cost and is less rapidly performed
with limited detection of non-GU pathology.
Summary
Unenhanced CT has been demonstrated to be the
most accurate and efficient diagnostic imaging means
to evaluate urinary lithiasis, with capability of direct-
ing management, and has become well accepted by
radiologists, urologists, and emergency department
physicians such that it is now the standard of practice.
It is the duty of the radiologist to be aware of proper
technique and the details of interpretation. The radiolo-
gist also has a duty to be aware of the limitations of
unenhanced CTfor detection and evaluation of various
nonstone disorders, particularly with poor patient
selection, and to extend the examination if appropriate.
Controversies and future developments include
cost containment with care for the selection of patients.
Further attempts to reduce radiation exposure should
be made. Optimal CT technique is not needed in
general merely to detect urinary lithiasis. A consensus
should be developed regarding use of CT in pregnant
patients. Further improvements in the digital scout
view would be useful for following patients.
Fig. 15. Clinical information: left flank pain. (A) Unenhanced CT demonstrates left caliectasis (arrow). Attenuation of the left
kidney was 35 Hounsfield units, of the right 25. (B) A 7 13 mm stone is lodged in the left ureter. (C) The stone is clearly
visible on CT scout view. (D) Normal unenhanced CTon a different patient demonstrates bilateral dense pyramids (arrowheads),
a finding that can be lost if there is obstruction.
Fig. 16. Clinical information: acute left flank pain. (A) There is mild left perinephric stranding and borderline pelviectasis on
unenhanced CT. (B) Stone is present: at UVJ or in bladder? Note it is to the left of midline. (C) Prone view documents stone is in
ureter at UVJ.
Fig. 17. Clinical information: left flank pain. (A) There is left hydronephrosis and stranding present on unenhanced CT. (B) Stone
is present: at UVJ or in bladder? Note it is in midline. (C) Prone view shows stone drops, clearly in bladder.
Fig. 18. Clinical information: left flank pain. (A) Unenhanced CT demonstrates left hydronephrosis and renal calculus. (B) The
left ureter could be followed to a less than 2 mm stone (arrow) in distal ureter; this is very likely to pass spontaneously. (C) The
stone was not visible on CT scout view nor on plain radiograph (shown).
Fig. 19. Clinical information: acute left flank pain and hematuria. (A) Unenhanced CT reveals mild left perinephric stranding and
hydronephrosis; note bulge of right kidney (arrow). (B) Small stone was demonstrated in left ureter (arrow). (C) Repeat CT after
stone passage done with images before and after intravenous contrast demonstrates the right renal lesion (arrow) is complex with
some enhancement. Laparoscopic resection of a partially cystic renal carcinoma was performed.
Fig. 20. Clinical information: 20-year old woman with right abdominal pain, no history of stones. (A) Unenhanced CT was
unremarkable. (B) Contrast-enhanced CT demonstrates patchy areas diminished enhancement typical of pyelonephritis,
documented later by cultures.
Fig. 21. Clinical information: 66-year-old man with left flank pain, microhematuria, history of mitral valve disease. (A) Un-
enhanced CT demonstrates asymmetric left perinephric stranding, but no hydronephrosis or stone shown. (B) Contrast-enhanced
CT reveals lack of enhancement of left kidney indicative of renal infarct from arterial embolus.
Fig. 22. Clinical information: 17-year-old woman, 22 weeks pregnant with right flank pain. (A) Unenhanced CT was performed
with reduced dose. Initial test image done with 80 milliampere seconds, 140 kV was adequate, showing no secondary signs. (B)
Study performed with single series with reduced dose was negative, precluding any further examinations.
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MR imaging of renal function
Ambrose J. Huang, MD, Vivian S. Lee, PhD, MD
*
, Henry Rusinek, PhD
Department of RadiologyMRI, New York University Medical Center, 530 First Avenue, HCC Basement,
New York, NY 10016, USA
The kidneys maintain homeostasis by filtering and
excreting metabolic waste products, regulating acid-
base balance, and moderating blood pressure and
fluid volume. Because decreasing renal function
accompanies renal disease, monitoring renal function
permits assessment of disease progression and prog-
nosis and is used to guide patient management and
therapy. Many noninvasive tests of renal function are
commonly used, but all have their drawbacks. Serum
creatinine levels and creatinine clearance are insensi-
tive measures of global function and cannot supply
information about individual renal function. Renal
scintigraphy can assess renal function but provides
limited anatomic information and exposes the patient
to radiation. CTand intravenous urography (IVU) can
provide functional and anatomic information, but
both use nephrotoxic contrast agents and also expose
the patient to radiation. The newest approach to
studying renal function uses MR imaging, which
skirts these handicaps by simultaneously offering
exceptional anatomic detail and functional informa-
tion without exposure to ionizing radiation or neph-
rotoxic contrast agents. MR imaging is the only
single imaging modality with the potential to deliver
a comprehensive anatomic and functional examina-
tion of the kidneys with minimal risk to the patient.
The MR imaging evaluation of renal function
typically centers on visualizing the passage of contrast
material through the kidney. The contrast agents used
in MR imaging are usually gadolinium chelates, such
as gadolinium diethylenetriamine pentaacetic acid
(Gd-DTPA, also known as gadopentetate dimeglu-
mine), although there are also more novel approaches,
such as arterial spin labeling. The paramagnetic prop-
erties of gadolinium cause a decrease in the T1 and T2
relaxation times of nearby tissues and fluids. The
physiologic behavior of gadolinium is governed by
the properties of the agent to which it is chelated.
DTPA is a substance that, like inulin, is freely filtered
by the glomerulus and is neither resorbed nor secreted
by the renal tubules, rendering it a convenient marker
of glomerular filtration. When bound to gadolinium,
its path through the kidneys can be traced with
T1-weighted MR imaging. Such imaging examina-
tions are referred to as MR renography.
The high spatial resolution of MR imaging allows
visualization of gadolinium contrast material within
distinct intrarenal regions, such as the cortex, the
medulla, and the collecting system (Fig. 1) [13].
Enhancement of the cortex primarily reflects perfusion
and glomerular filtration, whereas enhancement of the
medulla and collecting system, although dependent on
filtration, primarily reflects the condition of the renal
tubules. The improved resolution of MR imaging,
when compared with scintigraphy, can potentially
provide more accurate measurements of renal perfu-
sion or glomerular filtration, because these are based
on renal cortical measurements and are not con-
founded by tubular changes. Moreover, given that
different diseases affect different portions of the vas-
cular-nephron system, MR renography has the poten-
tial, unique among all noninvasive tests, to distinguish
glomerular from tubulointerstitial pathology.
This article first reviews some technical issues
surrounding functional renal MR imaging. Next is
discussed the determination of two important renal
functional parameters: renal blood flow (RBF) and
doi:10.1016/S0033-8389(03)00066-6
E-mail address: vivian.lee@med.nyu.edu (V.S. Lee).
Radiol Clin N Am 41 (2003) 10011017
glomerular filtration rate (GFR). Finally, specific
applications of functional renal MR imaging in the
arenas of renovascular disease (RVD), hydronephro-
sis, and renal transplantation are explored.
Technical issues
There are several technical issues relevant to MR
renography. Among them, the quantification of con-
trast concentration from MR imaging signal intensity
measurements, gadolinium dose optimization, and
image analysis issues, such as segmentation, have
proved quite challenging.
Quantification of contrast
One difficulty with Gd-DTPAenhanced MR im-
aging is the complex relationship between signal
intensity and Gd-DTPA concentration. MR imaging
signal intensity varies with pulse sequence parameters,
the studied tissues precontrast and postcontrast T1
values, and Gd-DTPA concentration [4]; furthermore,
above a certain concentration of Gd-DTPA, suscepti-
bility effects dominate and actually decrease the signal
intensity. This is in contrast to renal scintigraphy,
where the number of radioactive counts increases
linearly with the concentration of
99m
Tc-DTPA.
Most groups have used the relative signal intensity
ratio (SI SI
0
)/ SI
0
, where SI
0
represents baseline
signal intensity, to approximate Gd-DTPA concentra-
tion, relying on an assumed linear relationship be-
tween the two [3,58]. Although simple to implement,
this approach has several limitations. First, the as-
sumed linearity does not hold at higher Gd-DTPA
concentrations, where susceptibility effects come into
play. Second, differences across patients and MR
imaging systems make results difficult to generalize.
Third, it ignores the effects of flow on relative signal
intensity ratios measured in vessels, such as the aorta.
Rusinek et al [9] have proposed an alternative
approach to converting MR imaging signal intensity
to Gd-DTPA concentration that invokes two relation-
ships. The first is the linear relationship between a
tissues relaxation rate and the concentration of gado-
linium within it.
1
T1

1
T1V
Gd R; 1
where T1 and T1V are the observed and precontrast
relaxation times of the tissue being studied, respec-
tively, [Gd] is the concentration of gadolinium, and R
is the relaxivity of gadolinium (4.5 L/mmols).
The second is an empirically or theoretically
derived relationship between signal intensity and T1
that must be adjusted across patients by a multipli-
cative scaling factor.
SI k f T1; 2
where SI is observed signal intensity, k is a constant
multiplicative factor, and f is a monotonic relation-
ship between signal intensity and the tissues relaxa-
tion time, T1.
Given a tissues precontrast signal intensity and
T1 value, one can use equations 1 and 2 to derive the
concentration of gadolinium within the tissue based
on signal intensity measurements following contrast
administration. The requirement of monotonicity for f
is a restatement of the fact that above a certain Gd-
DTPA concentration, susceptibility effects govern the
effect of Gd-DTPA on surrounding tissue and prevent
the determination of Gd-DTPA concentration from
signal intensity.
Additional methods for directly estimating Gd-
DTPA concentration from MR renography images
include inversion recovery T1 mapping [10]; methods
based on the Look and Locker T1 measurement pulse
sequence (referred to as a Look-Locker methods)
[11]; and other dedicated T1 measurement methods,
such as T1 fast acquisition relaxation mapping [12].
These methods, however, are currently unable to
provide whole kidney imaging with sufficient tem-
poral and spatial resolution for MR renography.
Fig. 1. Three-dimensional MR renography in a healthy
volunteer (spoiled GRE sequence, TR/TE/2.2/0.8/9, matrix
134 256, coronal orientation, FOV 380 mm, slab thickness
96 mm, acquisition time 3 sec). On the left are 4 of 32 images
from an MR renography data set acquired 18 seconds after
2 mL of Gd-DTPAwere injected, showing marked aortic and
cortical enhancement (ad, anterior to posterior). On the
right are images from the same patient acquired (a) 0, (b) 18,
(c) 90, and (d) 240 seconds after injection of Gd-DTPA. Each
image is 1 of 32 images from a three-dimensional data set.
Note enhancement of the medulla (arrows) and the ureter
(open arrow).
A.J. Huang, V.S. Lee / Radiol Clin N Am 41 (2003) 10011017 1002
Gadolinium dose optimization
Although most groups have used standard doses of
gadolinium for MR renography (0.1 to 0.2 mmol/kg),
studies suggest that lower doses may be advanta-
geous because they avoid the susceptibility effects
that occur when gadolinium is concentrated in the
renal medulla and collecting system. Taylor et al [4]
tested several combinations of two-dimensional fast
low angle shot (FLASH) pulse sequence parameters
on a phantom to find an optimal sequence (repetition
time [TR] = 38 milliseconds, echo time [TE] = 5 mil-
liseconds, q = 40 degrees) for which the relationship
between signal intensity and Gd-DTPA concen-
tration was approximately linear over a clinically
relevant range of concentrations (0 to 1 mmol/L).
They tested three doses of Gd-DTPA (0.1, 0.05, and
0.025 mmol/kg). When MR renography signal in-
tensity-versus-time curves (signal intensity curves,
for short) were compared with renal scintigraphic
time activity curves, correlation was generally poor.
In their study, however, the lowest dose of Gd-DTPA
(0.025 mmol/kg) yielded signal intensity curves most
similar to scintigraphic time activity curves, suggest-
ing that the undesired role that susceptibility effects
can play in MR renography is significant. This study
underscores the need for a clear grasp of the rela-
tionship between signal intensity and Gd-DTPA
concentration when conducting MR renography
studies [4].
Rusinek et al [9] used Monte Carlo simulations to
determine optimal doses of Gd-DTPA for determin-
ing such computed functional parameters as GFR.
Like Taylor et al [4], the group found that lower
doses of Gd-DTPA were better for measurements
of renal function: 2.8 to 3.8 mL (approximately
0.015 mmol/kg) in normal patients, and 3.8 to
5.6 mL (approximately 0.025 mmol/kg) in those with
renal dysfunction [9]. These doses, substantially
lower than those typically used, have the additional
benefit of making it possible to combine MR renog-
raphy with a conventional contrast-enhanced MR
imaging examination in the same session.
Image analysis
For image analysis of MR renography, functional
information is typically extracted by placing regions
of interest (ROIs) over the cortex and medulla and
plotting their signal intensities over time. Image
postprocessing faces several challenges. First, most
groups perform manual ROI analysis, which is labor-
and time-intensive and is subject to operator errors.
Moreover, ROI analysis usually provides only a
sampling of the renal signal intensity curves rather
than a more desirable global assessment. Also,
whereas cortical ROI placement is relatively straight-
forward [13], satisfactory medullary ROI placement
is contingent on adequate corticomedullary differen-
tiation soon after contrast injection.
To address this last problem, De Priester et al [13]
have developed an algorithm that exploits the relative
ease of cortical ROI placement to quantify and
correct for the commingling of cortical and medullary
signal intensity, or volume averaging, thus facilitating
the confident placement of medullary ROIs. Let the
signal intensity curve of a corticomedullary ROI,
CM(t), be decomposed into its cortical (C(t)) and
medullary (M(t)) components.
CMt f
C
Ct f
M
Mt
f
C
Ct 1 f
C
Mt; 3
where f
C
and f
M
represent the cortical and medullary
fractions of the ROI, respectively.
Solving for M(t) yields
Mt
CMt f
C
Ct
1 f
C
4
Let time t = 0 be defined as the last time at which
the cortical ROI (and hence the corticomedullary
ROI) remains unenhanced. By applying similar rea-
soning that was used to obtain equation 3, we get
CMt CM0
f
C
Ct C0 1 f
C
Mt M0 5
During the period soon after contrast injection,
however, the medulla has not yet enhanced, so M(t) =
M(0). Equation 5 can be simplified, and solving for
f
C
yields
f
C

CMt CM0
Ct C0
6
Equation 6 can then be substituted into equation 4
to compute the medullary signal.
De Priester et al [13,14] tested this algorithm on
five healthy volunteers and nine clinically asymp-
tomatic post renal transplant patients. The authors
acquired MR renography images using a gradient
recalled echo (GRE) sequence following administra-
tion of Gd-DTPA. They compared signal intensity
curves generated from ROIs placed over purely
medullary regions in the healthy volunteers with
those calculated from the placement of corticomedul-
lary ROIs with varying cortical fractions. Although
the algorithm was able to generate the correct general
shape for the calculated medullary curves, there was
an overestimation of their absolute signal intensities
that was more pronounced in curves generated from
corticomedullary ROIs with larger cortical fractions,
suggesting that there likely are nonenhancing struc-
tures within the cortex or medulla that are not
accounted for by the algorithm [13].
Boykov et al [15] have developed a semiauto-
mated algorithm that aims to segment renal MR
renography images into cortex, medulla, and collect-
ing system regions based on a graph cuts approach
that first uses a temporal Markov model to represent
voxels as vectors of time histories of signal intensi-
ties. The algorithm then seeks a globally optimal seg-
mentation while satisfying user-defined constraints.
The authors group tested the algorithm on simulated
MR renography data of normally and abnormally
functioning right and left kidneys subjected to vari-
ous levels of noise and blur. Image postprocessing
times dramatically decreased from over 2 to 3 hours
to roughly 8 minutes per patient. On average, over all
blur and noise levels, voxels tended to be over-
classified into the cortex and the collecting system
and underclassified into the medulla. For levels of
blur and noise that were representative of clinical
data, however, these segmentation errors resulted in
less than 5% root-mean-square errors in the signal
intensities of these compartments [16]. Preliminary
evaluation of this algorithm looks favorable, but
testing on patients is still needed.
Renal perfusion imaging
Reduction in renal perfusion or RBF, typically
from renal artery stenosis (RAS), causes a decrease in
GFR and can ultimately lead to permanent renal
damage. The anatomic level and degree of RAS
typically used to describe it incompletely define renal
status, because vessel diameter reductions of up to
70% can occur before jeopardizing renal perfusion.
Evaluating renal perfusion should improve characteri-
zation of RAS. Other clinical indications for the
assessment of renal perfusion include renal transplant
dysfunction, chronic ischemic nephropathy, and drug
nephropathy. In nuclear medicine, the measurement
of inflow of radionuclide tracers is used to determine
renal perfusion, but exposure to radiation and poor
anatomic detail are drawbacks that limit its use.
Methods that have been used in MR imaging include
first-pass contrast-enhanced imaging using extravas-
cular gadolinium-based contrast agents, imaging us-
ing intravascular contrast agents, arterial spin
labeling techniques, and blood oxygenation level
dependent imaging.
Renal perfusion imaging using extravascular contrast
agents
Vallee et al [17] invoked the similar properties of
Gd-DTPA and
99m
Tc-DTPA to apply the microsphere
technique, which is used in nuclear medicine to
quantify RBF, to Gd-DTPAenhanced MR imaging.
The microsphere theory relates RBF to the amount of
contrast trapped in the kidney according to the
following equation.
RBF
cardiac output

contrast trapped in kidney
total contrast injected
7
The amount of contrast trapped in the kidney is
a theoretical amount, because unlike microspheres,
Gd-DTPA is not trapped in the kidney, although it is
assumed that extravascular leakage of Gd-DTPA is
inconsequential during the initial enhancement peri-
od. The theoretical amount of contrast can be calcu-
lated given the initial slopes of the renal Gd-DTPA
and arterial wash-in curves and the arterial residue
function, which is the integral of the arterial input
function fitted to a gamma variate to correct for
recirculation [18,19]. Relating the arterial integral to
the total amount of contrast injected [20] yields an
expression for RBF per unit volume.
RBF
Volume
max slope
kidney
max D1=T1
aorta
8
This formula states that RBF per unit volume can
be calculated using the maximum rate of contrast
uptake by the kidney and the maximum contrast-
induced change in relaxivity in the aorta. The authors
converted signal intensity to T1 using an in vitro
phantom-derived relationship between signal inten-
sity and T1.
Vallee et al [17] used this method to measure
cortical and medullary blood flow in 27 patients in
three patient groups: (1) normal renal function as
determined by serum creatinine level, (2) RAS, and
(3) renal failure. They found low cortical blood flow
in those patients with RAS compared with those with
normal renal function and low cortical and medullary
blood flows in those patients with renal failure
compared with those with normal renal function.
Values calculated were comparable with published
RBF measurements obtained using other modalities,
including dynamic CT,
133
Xe washout, and positron
emission tomography.
Renal perfusion imaging using intravascular contrast
agents
Although assumptions about the limited extent
of extravascular leakage of contrast during initial
enhancement may be valid, intravascular agents are
preferable for the measurement of renal perfusion.
Prasad et al [21] investigated renal cortical perfu-
sion imaging using an exogenous intravascular
contrast agent, MS-325, which binds to albumin
after injection. The group acquired MS-325
enhanced perfusion images with a turbo FLASH
sequence in seven pigs that underwent surgically
induced RAS, and they expressed regional blood
flow as the ratio of regional blood volume to indi-
cator mean transit time. MR imaging measurements
of renal perfusion were consistent with microsphere
measurements, but a slight elevation of the former
may represent a limitation of this technique. Inter-
estingly, there was minimal decrease in renal per-
fusion even in the face of severe RAS, possibly
related to the kidneys innate capacity to regulate
blood flow. Although these results are encouraging,
intravascular contrast agents have yet to be ap-
proved for RBF measurement.
Renal perfusion imaging using arterial spin labeling
techniques
An alternative approach to measuring renal perfu-
sion with exogenous contrast agents uses arterial spin
labeling techniques, and early results have been prom-
ising. Prassad et al [22] studied the efficacy of using
both signal targeting with alternating radiofrequency
(STAR) angiography and STAR with echo-planar
imaging for readout (EPISTAR) perfusion imaging
to characterize surgically created RAS in pigs.
EPISTAR imaging revealed decreased signal intensi-
ties in kidneys supplied by stenotic renal arteries.
Moreover, correlating the perfusion images with con-
ventional selective angiograms showed that segmental
regions demonstrating reduced signal intensity were
supplied by occluded branch vessels. When the
authors used the typical criterion of 70% stenosis by
conventional angiography to indicate a positive study,
the differences in signal intensity curves were 100%
sensitive and 100% specific for the detection of renal
perfusion abnormalities. Furthermore, differences in
these curves were more pronounced in the presence of
a vasodilator such as acetylcholine, which is consistent
with the results of other investigators [23,24].
Other groups have reported similarly promising
results using different methods [25,26]. Although
these studies show that using MR imaging to quantify
renal perfusion is feasible, no group has validated
these methods against an accepted standard, and these
methods have not been commercially implemented for
widespread use. Further investigation is warranted.
Renal perfusion imaging using blood oxygenation
level dependent imaging
Blood oxygenation level dependent (BOLD) im-
aging relies on the different magnetic properties of
oxyhemoglobin and deoxyhemoglobin to achieve tis-
sue contrast on T2*-weighted images [27]. Although
BOLDimaging has been used to measure perfusion, its
value in renal applications may reside in its capacity to
quantify oxygen use noninvasively. BOLD imaging is
particularly suited for assessing oxygenation of the
renal medulla, which normally functions at hypoxic
levels [28]. Prasad et al [27,29] used BOLDimaging to
study the effects of furosemide, acetazolamide, and
water diuresis on renal oxygenation in 12 healthy
volunteers. They found that furosemide decreased
medullary R2* (1/T2*) in all patients, indicating an
increase in medullary oxygenation, but it did not
significantly affect cortical R2*. The furosemide-in-
duced decrease in activity, and hence oxygen use, of
proximal tubular transporters explains these findings
[27]. Acetazolamide did not significantly affect corti-
cal or medullary R2*. Water diuresis had similar
effects on the cortex and medulla as furosemide,
although the authors hypothesized in this case that
the findings were caused by changes in regional blood
flow [27].
These preliminary studies illustrate the potential
for BOLD imaging to assess renal medullary oxy-
genation noninvasively; however, this technique has
a limited capacity for determining whether changes in
oxygenation are caused by differences in blood flow
or differences in oxygen use [30].
Glomerular filtration rate
Monitoring renal function is essential in many
causes of acute and chronic renal insufficiency to
assess prognosis, response to treatment, progression
of disease, and nephrotoxicity associated with thera-
peutic agents. Clinicians often use serum creatinine
levels or creatinine clearance for this purpose, because
measuring them is relatively easy and safe. Serum
creatinine, however, is an insensitive indicator of renal
dysfunction; its production varies across individuals,
and diet and medications can affect its kinetics [31].
Clearances of inulin and DTPA are indicators of GFR
and are better markers of renal function, but these
measurements require multiple blood and urine col-
lections, and they do not provide unilateral renal
functional information.
For less invasive measurements of renal function
using MR imaging, early work showed that even
without contrast administration, the loss of cortico-
medullary differentiation on T1-weighted MR imag-
ing indicated a serum creatinine level greater than
3 mg/dL [32]. Recently, several MR imaging tech-
niques for the noninvasive measurement of single
kidney GFR have been developed based on the
imaging of the renal uptake of gadolinium chelates.
Three categories of GFR measurements using MR
imaging are reviewed: (1) global GFR determination
using blood clearance of gadolinium-based contrast
agents, (2) single kidney GFR determination using
MR relaxometry, and (3) single kidney GFR deter-
mination using intrarenal kinetics.
Global GFR using blood clearance of
gadolinium-based contrast agents
In their 1992 paper, Choyke et al [33] compared
global GFR determined by clearance of
99m
TcDTPA
(GFR
Tc
) with that determined by clearance of
Gd-DTPA (GFR
Gd
) in 90 patients based on three
separate urine and blood samples using the stan-
dard equation
GFR
tracer

tracer
urine
V
tracer
plasma
; 9
where V is the urine flow rate, and [tracer]
x
is the
concentration of tracer in x.
The authors calculated Gd-DTPAconcentrations in
urine and plasma by first determining the T1 of each
fluid using an nuclear magnetic resonance (NMR)
spectrometer and then using an experimentally derived
relationship to convert T1 into Gd-DTPA concentra-
tion. GFR
Gd
correlated well with GFR
Tc
(correlation
coefficient = 0.94), and the coefficient of variation of
their differences was 3.6%. Ros et al [1] performed a
similar study that combined plasma Gd-DTPA clear-
ance estimates of GFR with MR angiography and MR
renography. Across six patients, GFR
Gd
and GFR
Tc
correlated well (correlation coefficient = 0.98), and the
standard error was 3.85 mL/minute. Although clear-
ance of Gd-DTPAcan be used to measure global GFR,
the use of NMR spectrometers and the repeated
sampling of blood and urine required preclude wide-
spread clinical use.
Single kidney GFR using MR relaxometry
Although Gd-DTPA clearance was the basis of the
global GFR studies previously mentioned, an alter-
native approach enables the measurement of single
kidney GFR based on calculations of the single
kidney extraction fraction (EF) of a tracer like inulin
or Gd-DTPA. The method is based on imaging and
does not require blood or urine collection. EF is
defined as
EF
tracer

tracer
artery
tracer
vein
tracer
artery
10
Equation 1 relates observed T1 in a tissue to
gadolinium concentration. Rearranging and substitut-
ing equation 1 into equation 10, we get
EF
Gd

T1
precontrast
T1
vein

T1
vein
T1
artery
T1
precontrast
T1
artery

11
Once EF is determined, GFR can be calculated
according to the following.
GRF EF RBF 1Hct; 12
where RBF is renal blood flow and Hct is hematocrit.
Three groups have published results using this
approach to measure single kidney GFR [3436].
Dumoulin et al [34] tested this approach on human
volunteers and calculated EF using an inversion
recovery sequence to determine the T1 values of
moving blood in the renal artery and renal vein.
The EFs obtained in the study spanned a wide range
and were inconsistent with data published in previous
clearance studies, but it was believed that clearance
studies were unsuitable for judging the EFs and GFRs
calculated with this method.
Niendorf et al [35] performed a study to validate
this technique against single kidney inulin clearance
measurements in six pigs. The inversion recovery
sequence they used to obtain T1 measurements, based
on a Look-Locker method [11], was modified to use
GRE or EPI readout pulses for measuring relaxation
recovery. Several advantages resulted from this ap-
proach, including decreased sensitivity to off-reso-
nance effects, the use of large readout pulses, and
increased vessel contrast [35]. The group used the
renal vein to derive renal venous T1 and the inferior
vena cava to approximate renal arterial T1, and they
measured RBF using phase-contrast flow quantifica-
tion MR imaging in the renal artery or renal vein.
Although GRE imaging provided better spatial reso-
lution, EPI was faster and facilitated breathhold
acquisitions. EF
Gd
and GFR
Gd
correlated well with
EF
inulin
and GFR
inulin
(linear regression slopes for
measuring GFR were 0.81 and 0.85 for GRE and EPI
techniques, respectively), and their respective differ-
ences were statistically insignificant.
Coulam et al [36] used a similar technique to
examine the effects of RAS on EF and GFR in a pig
model. MR imaging sequence modifications included
cardiac gating, adiabatic inversion, interleaved spiral
readouts, and spectral-spatial excitation pulses. The
authors measured T1 relaxation using cardiac-gating
during suspended respiration and approximated arte-
rial input T1 using either the inferior vena cava or the
aorta, and they obtained RBF with phase-contrast
imaging of the renal arteries. EF
Gd
and EF
inulin
corre-
lated well (correlation coefficient = 0.77, P< 0.01),
although EF
Gd
values were 22% less than EF
inulin
( P = 0.01). In this study, the authors completed all
calculations of EF
inulin
before computing EF
Gd
, and
they hypothesized that the additional anesthesia time
coupled with declining renal function adversely af-
fected EF
Gd
. In the kidneys with RAS, EF
Gd
, EF
inulin
,
RBF, and GFR were all significantly reduced.
This approach to measuring single kidney GFR is
innovative, but it faces several technical challenges,
including difficulties estimating gadolinium concen-
tration and determining RBF using phase-contrast
flow measurements in small vessels.
Single kidney GFR based on intrarenal kinetics
Gadolinium chelates traverse the kidney in a pre-
dictable fashion, progressing from the arterial blood to
the cortex, medulla, and collecting system. This re-
flects the normal passage of these substances through
the nephron from the glomerular capillary through
Bowmans capsule into the proximal convoluted tu-
bule (cortex), through the loop of Henle (medulla), the
distal convoluted tubule, the collecting duct (cortex
and medulla), and finally through the renal calyx. If
one considers gadolinium chelates to be tracers whose
passage through the kidney reflects the behavior of
other glomerular agents, then one can apply tracer
kinetic models to interpret patterns of intrarenal
enhancement in terms of parameters, such as GFR.
Baumann and Rudin [6] proposed a first-order
kinetic model of the kidney that consists of two
compartments, the cortex and medulla, and a rate
constant between the two representing the rate of
clearance of tracer from the cortex.
dGd
m
dt
k Gd
c
; 13
where [Gd]
m,c
are the time-varying concentrations of
gadolinium in the medulla and cortex, respectively,
and k is the flow rate between compartments.
In normal rats, the authors compared MR renogra-
phy images acquired with a rapid acquisition with
relaxation enhancement sequence with those acquired
with a snapshot sequence, using gadolinium tetraazo-
cyclododecane-tetraacetate (Gd-DOTA), a glomerular
contrast agent. The group converted signal intensities
to T1 values using available formulas relating signal
intensity to T1 for the rapid acquisition with relaxation
enhancement and snapshot sequences, computed
Gd-DOTA concentration from T1 values using equa-
tion 1, and determined k by fitting the resulting corti-
cal and medullary Gd-DOTA concentration curves to
equation 13. The snapshot sequence produced superior
images compared with the rapid acquisition with relax-
ation enhancement sequence and was less affected by
susceptibility effects at high Gd-DOTA concentra-
tions. Using the snapshot sequence, the derived k
was 3.4 F 0.5 minutes
1
. Although plotting the initial
rate of increase of Gd-DOTA concentration in the
medulla against the administered dose of Gd-DOTA
did indeed reveal a linear dependence, lending support
to the proposed first-order kinetic model of glomerular
filtration, establishing the accuracy of this technique
requires comparison to a reference standard.
Laurent et al [37] used Baumann and Rudins [6]
first-order kinetic model and a snapshot sequence to
calculate GFR
Gd
in their study of the effects of
hypertension on renal function in rats. A few days
after the MR imaging experiment, they compared
GFR
inulin
, calculated from the clearance of [
3
H]inulin
using equation 9, with GFR
Gd
. GFR
Gd
and GFR
inulin
correlated well in the 17 rats studied (correlation
coefficient = 0.75).
Smith et al [38] estimated GFR using a different
two-compartment model, which was confined to the
cortex. In their model, the arteries and capillaries form
the first compartment, and the proximal convoluted
tubules form the second. Two rate constants, k
in
and
k
out
, describe the flow into and out of the proximal
tubules; k
in
represents GFR. The authors generated a
renal cortical Gd-DOTA concentration curve using a
two-dimensional cardiac-gated fast T1-weighted
spoiled GRE sequence following a 0.05 mmol/kg
injection of Gd-DOTA and fitted it to this model to
estimate GFR. For the four patients studied with this
approach, GFR ranged from 16 to 71 mL/min/100 g of
kidney cortex. Although these values are similar to
values reported in the literature, validating this method
against established standards remains to be done.
The authors group has described initial results
with a more expansive multicompartmental model of
the entire vascular-nephron system [39]. The model
considers the distinct cortical and medullary functional
nephron units (artery-capillary, proximal convoluted
tubule, loop of Henle, distal convoluted tubule, col-
lecting duct, and calyces-ureter) as separate compart-
ments (Fig. 2). The cortex, medulla, and collecting
system are then expressed as a linear combination of
these compartments. A series of first-order differential
equations models the course of Gd-DTPA through
pairs of compartments over time. Like Smith et als
k
in
[38], the rate constant describing the passage of
Gd-DTPA from the arteries and capillaries to the
proximal tubules represents GFR. Using a fast three-
dimensional MR renography technique, the authors
implemented this model and computed GFRin a series
of nine subjects (18 kidneys) and found good correla-
tion (correlation coefficient = 0.76) with same-day
gamma camera and blood clearancederived mea-
sures of single kidney GFR using
99m
TcDTPA [40].
One advantage of this model over previous ones is its
inclusion of renal structures distal to the proximal
tubules. In principle, this model can assess tubular
physiology and pathology based on MR renogra-
phy, both of which have been almost impossible to
evaluate noninvasively.
Angiotensin converting enzyme inhibitor MR
renography for RVD
Of the 60 million people with hypertension, an
estimated 1% to 5% have RVD as the underlying
cause [41]. As one of the few potentially curable
causes of hypertension, RVD remains an important
yet challenging diagnosis. Not all patients with RAS
have RVD; in fact, those with essential hypertension
tend to develop accelerated atherosclerosis, which
can lead to RAS. These diagnostic limitations have
generated controversies surrounding treatment. Van
Jaarsveld et al [42] concluded from their multicenter
trial that treating hypertension secondary to RVD
with balloon angioplasty was not much better than
treating it with medicine alone, although the criterion
they used for RVD (RAS causing only greater than
50% narrowing) may undermine their conclusions.
Most anatomic tests, such as conventional angi-
ography, MR angiography, and CT angiography, are
limited in their ability to diagnose RVD because they
rely on RAS as the sole criterion. Angiotensin con-
verting enzymeinhibitor (ACE-I) renal scintigraphy
is the best predictor of response to therapy because it
is a functional test of renal ischemia. It does not,
however, supply anatomic information needed for
therapeutic planning.
When performed with MR angiography, MR
renography has the potential to provide an anatomic
and functional evaluation of RVD. Preliminary data
are encouraging, although small sample sizes and
susceptibility effects from concentrated contrast in
the medulla and collecting system as a result of
standard doses of gadolinium have limited early
studies [1,43,44]. In a study of 10 patients, Ros et al
[1] used a turbo FLASH sequence with 0.05 mmol/kg
of Gd-DTPA and time-of-flight MR angiography to
diagnose RAS. They described one patient in whom
severe left RAS shown by conventional angiography
corresponded to decreased left medullary enhance-
ment depicted on MR renography. Using 0.1 mmol/kg
or more of gadolinium, Grenier et al [43] observed a
band of low signal intensity on T1-weighted images
Fig. 2. Multicompartmental model of the vascular-nephron system for analysis of MR renography data in terms of physiologic
parameters. Compartments of the model are intended to reflect closely the anatomy and function of the nephron. Solid arrows
indicate the passage of plasma or tracer-containing tubular fluid between compartments at flow rates Q
ij
, whereas dotted arrows
indicate tracer-free fluid resorption, F
i
, fromthe tubular compartments into the vasa recta. Q
PA
= GFR. (FromLee VS, et al. Analysis
of dynamic three-dimensional (3D) MRrenography: regional characterization by multicompartmental modeling. In: Proceedings of
the International Society for Magnetic Resonance in Medicine. Glasgow, Scotland, UK: 2001. p. 2059; with permission.)
that progressed centripetally over the course of more
than 4 minutes. The susceptibility effects of con-
centrated gadolinium in the medulla and collecting
system caused this signal loss and precluded con-
trast quantification.
The successful use of an ACE-I (such as capto-
pril) in renal scintigraphy is the basis for its in-
corporation into MR renography protocols [3].
Decreased renal perfusion pressure in patients with
RAS activates the renin-angiotensin system and
increases production of angiotensin II. Angiotensin
II causes vasoconstriction of the efferent glomerular
arteriole and restores renal perfusion pressure and
glomerular filtration to normal or near-normal levels.
This compensated RAS may not manifest any per-
fusion or filtration abnormalities on renal scintigra-
phy or MR renography. Administering an ACE-I
lowers GFR in the setting of RVD because it blocks
the production of angiotensin II, which decreases
efferent glomerular arteriolar vasoconstriction and
reduces perfusion pressure.
Prasad et al [45] used captopril MR renography
to evaluate the hemodynamic significance of uni-
lateral RAS in their porcine model. They performed
T1-weighted MR renography using a three-dimen-
sional fast imaging with steady state precession
sequence and a 0.1 mmol/kg bolus of Gd-DTPA.
The authors showed that the signal intensity curves
of the right versus left kidneys differed little in the
absence of captopril. Following captopril administra-
tion, however, the kidney supplied by the stenotic
renal artery demonstrated little washout of Gd-DTPA
during the imaging period. These results are consis-
tent with those of ACE-I renal scintigraphy.
The authors group implemented an ACE-I MR
renography protocol combined with MR angiography
in 32 patients with suspected RVD [3]. Imaging
consisted of a two-dimensional turbo FLASH se-
quence using a 2-mL (0.013 mmol/kg) dose of
Gd-DTPA for MR renography followed by con-
trast-enhanced MR angiography using a standard
(0.14 mmol/kg) dose of Gd-DTPA. It was found
that patients with elevated serum creatinine levels
( 2 mg/dL) had depressed cortical and medullary
signal intensities at 1 to 4 minutes following Gd-DTPA
injection when compared with patients with normal
serum creatinine levels ( < 2 mg/dL) (Fig. 3). Effects
of the ACE-I on cortical and medullary enhancement
depended on the presence of RAS and the serum
creatinine level. In patients with RAS, medullary
enhancement following ACE-I administration was
slightly less than in those patients without RAS
( P values ranged from 0.1 to 0.2), whereas there was
no such difference without ACE-I administration.
Patients with elevated serum creatinine levels had
depressed enhancement regardless of the presence or
absence of RAS and regardless of ACE-I administra-
tion. This inability to further characterize RVD in
Fig. 3. Renal cortical (A) and medullary (B) relative signal intensity curves with standard error bars. Patients with serum
creatinine less than 2 mg/dL (solid line) are compared with those with elevated serum creatinine (dotted line). Decreased
medullary enhancement over 1 to 3 minutes in patients with renal insufficiency (dotted line, B) reflects less Gd-DTPA filtered at
the glomerulus and less passing into the loop of Henle (medulla). (From Lee VS, et al. MR renography with low-dose
gadopentetate dimeglumine: feasibility. Radiology 2001;221:3719; with permission.)
patients with renal insufficiency represents a limita-
tion of this approach. Among patients with normal
serum creatinine levels, however, ACE-I administra-
tion did unmask decreased GFR by depressing med-
ullary enhancement in patients with RAS (Fig. 4).
ACE-I MR renography may even be useful in
transplant RAS. Sharma et al [46] studied the role of
ACE-I MR renography in 11 post renal transplant
patients with hypertension. They performed ACE-I
MR renography using a turbo FLASH sequence and a
2-mL dose of Gd-DTPA in conjunction with three-
dimensional phase-contrast MR angiography of the
transplant renal arteries. In patients with less than
40% RAS, cortical signal intensity curves before and
after injection of 50 mg of captopril did not differ
significantly. The cortical signal intensity curves of
patients with at least 40% RAS had a lower peak than
those of patients with less than 40% RAS; captopril
exaggerated these differences.
These results illustrate the promise of ACE-I MR
renography for evaluating hemodynamically signifi-
cant RAS, although whether or not this technique is
superior to conventional anatomic studies in its
ability to predict a response to revascularization
remains debatable.
MR urography for hydronephrosis
Hydronephrosis is dilatation of the renal collect-
ing system. It may be congenital or acquired, ob-
structive or nonobstructive, and clinically significant
or insignificant. The goals of the imaging evaluation
of hydronephrosis are threefold: (1) delineation
of the extent of dilatation of the collecting system;
(2) diagnosis of an obstructing cause, if any; and
(3) evaluation of its effects on renal function. Many
imaging modalities have been applied to this prob-
lem. Both ultrasound and IVU primarily evaluate the
morphology of the urinary tract and have difficulty
distinguishing dilated and obstructed urinary tracts
from those that are merely dilated. Diuretic renal
scintigraphy, despite its poor spatial resolution, can
contribute functional information to the assessment,
but the test suffers an unacceptably high false-posi-
tive rate [47]. Contrast-enhanced CT can provide
functional information and excellent anatomic infor-
mation, but the cost of the necessarily high radiation
doses is problematic, particularly in the pediatric
population, and the risk of nephrotoxicity associated
with iodinated contrast agents is unsuitable for those
with renal insufficiency. Faster imaging and non-
nephrotoxic contrast agents have rendered MR imag-
ing increasingly applicable for the evaluation of
genitourinary diseases in general and hydronephrosis
in particular [8,4850]. In addition, MR imaging
eliminates the exposure to ionizing radiation and
nephrotoxic agents inherent in the other modalities.
These imaging strategies are collectively termed
MR urography. Not surprisingly, lessons learned
from interpreting IVU or CT studies readily apply to
the interpretation of MR imaging studies (Fig. 5).
Wen et al [7] studied the effectiveness of Gd-
DTPAenhanced MR imaging in assessing the func-
tion of three classes of rat kidneys: (1) nonobstructed
control, (2) partially obstructed, and (3) completely
obstructed. They acquired GRE images following the
injection of 1 mL/kg of Gd-DTPA. The partially
obstructed kidneys demonstrated delayed contrast
enhancement and washout when compared with the
normal controls. These changes were more pro-
nounced in the completely obstructed kidneys, where
there was continued accumulation of contrast in the
cortex and medulla and delayed appearance of con-
trast in the collecting system. These findings are
analogous to the classic delayed nephrogram and
Fig. 4. Middle-aged hypertensive woman with mild left RAS by MR angiography (arrowhead). MR renography shows normal
medullary enhancement at baseline and decreased medullary enhancement following angiotensin converting enzyme inhibitor
injection, implying significant stenosis. (Modified from Lee VS, et al. MR renography with low-dose gadopentetate dime-
glumine: feasibility. Radiology 2001;221:3719; with permission.)
delayed pyelogram observed during the IVU and CT
evaluations of obstructive hydronephrosis.
MR urography is superior to other modalities
because it provides better anatomic and functional
imaging in a single setting. Rohrschneider et al [48]
compared MR urography with a combination of
ultrasound, diuretic renal scintigraphy, and IVU for
the evaluation of 20 piglets that underwent surgically
induced urinary tract obstruction. They performed
static MR imaging using a T2-weighted three-dimen-
sional inversion recovery turbo spin echo sequence,
dynamic MR imaging using a two-dimensional
T1-weighted GRE sequence using 0.1 mmol/kg of
Gd-DTPA and 0.3 mg/kg of furosemide for distention
of the urinary tract, and diuretic renal scintigraphy
using
99m
Tc mercaptoacetyltriglycine and 0.5 mg/kg
of furosemide. MR urography showed the level of
stenosis and the more proximal urinary tract in all
of the cases, whereas IVU showed the same in only
half of the cases. Ultrasound almost never showed
Fig. 5. MR images of a 64-year-old man with a history of bladder cancer cystectomy and neobladder construction. (A) A
coronal single-shot T2-weighted image shows left-sided hydronephrosis and is suspicious for obstruction. (B) A slightly more
anterior image from the same coronal T2-weighted acquisition again shows dilatation of the renal calyces and ureterectasis.
(C) A coronal maximum intensity projection of a Gd-DTPAenhanced three-dimensional spoiled GRE acquisition obtained
5 minutes after intravenous injection of gadolinium shows prompt excretion into the dilated collecting system, indicating
absence of functional obstruction.
the level of stenosis. MR urography was also supe-
rior to IVU and ultrasound in demonstrating the
urinary tract distal to the stenosis. A distinct advan-
tage of MR urography was its ability to detect other
findings, such as various fluid collections (using the
static sequence) and their causes (using the dynamic
sequence to depict contrast extravasation). The
authors used signal intensity curves to characterize
relative renal function and urinary excretion, the
results of which agreed well with results obtained
using diuretic renal scintigraphy.
Katzberg et al [8] also investigated the quantita-
tive analysis of MR renography data in their ana-
tomic and functional evaluation of the kidneys of
11 patients with suspected unilateral hydronephrosis.
MR renography images consisted of three 8-mm thick
coronal sections acquired with a fast spoiled GRE
sequence following injection of 0.05 to 0.5 mmol/kg
of gadolinium-based contrast. Although the small
size and modest number of cases of obstructive
hydronephrosis limited this study, the medullary
enhancement pattern was delayed in hydronephrotic
compared with normal kidneys. Whether a qualitative
interpretation of MR renography requires supplemen-
tation with quantitative analysis to diagnose func-
tional obstruction, however, remains to be established.
A related application is the differentiation of
hydronephrosis from pyonephrosis, which is not
always straightforward. The typical diagnostic criteria
used are sonographic (an anechoic calyceal system in
the former and a heterogeneously echoic calyceal
system in the latter), but these are not reliable [51].
Conventional MR imaging also has difficulty sepa-
rating the two conditions, because both often appear
hypointense on T1-weighted images and hyperintense
on T2-weighted images. Chan et al [51], using
diffusion-weighted imaging to study 12 consecutive
patients with pelvicaliectasis detected by ultrasound,
found that hydronephrotic collecting systems had
significantly higher apparent diffusion coefficients
than pyonephrotic collecting systems at a b-factor
of 1000 s/mm
2
(mean apparent diffusion coefficients
= 2.98 F0.65 10
3
mm
2
/s versus 0.64 F0.35
10
3
mm
2
/second, P< 0.001).
MR imaging for renal transplant evaluation
Complications following renal transplantation are
generally categorized as surgical or medical. Surgical
complications usually manifest themselves in the
immediate or early postoperative period and include
RAS and subsequent infarction, renal vein thrombo-
sis, urinary leak, and lymphocele. Typical findings
for these entities on conventional MR imaging have
been described [5255]. Medical complications are
diagnostically more problematic. They include acute
allograft rejection; chronic allograft rejection; acute
tubular necrosis; cyclosporine A toxicity; infection;
and transplant-associated malignancies (lymphoma
and posttransplant lymphoproliferative disorder)
[52]. In the early posttransplant period, acute allograft
rejection and acute tubular necrosis are the most
important causes of renal allograft dysfunction [2],
and the long-term function of the renal graft and
survival of the patient depend crucially on distin-
guishing these two entities from one another, a task
made more difficult by the possibility of their coex-
istence in the same patient.
Imaging modalities currently used to assess renal
allograft dysfunction include Doppler ultrasound and
renal scintigraphy, neither of which can differentiate
reliably among the medical causes of impaired renal
function [56]. Definitive diagnosis of these condi-
tions often requires a renal biopsy, an invasive
procedure with risks that include hemorrhage, arte-
riovenous fistula, pseudoaneurysm, and infection,
each of which alone can lead to loss of the renal
allograft. The challenge is to find a reliable, non-
invasive, and comprehensive method of examining
the renal allograft and obviate renal biopsy. Early
results with functional MR imaging are promising
and are based on visualizing distinct patterns of
gadolinium enhancement associated with pathologies
that affect different portions of the nephron (Fig. 6).
Szolar et al [2] used MR renography to examine
renal allografts during the posttransplant periods of
23 consecutive patients with clinically suspected
acute allograft rejection or acute tubular necrosis
and demonstrated distinct patterns of cortical and
medullary enhancement in the two groups. Using
Gd-DTPAenhanced GRE images, 12 out of 13 pa-
tients with pure acute tubular necrosis were found to
have a slight decrease and delay in cortical enhance-
ment and a uniphasic instead of biphasic medullary
enhancement pattern when compared with normal
controls. All 10 patients with acute allograft rejection
had significantly decreased cortical and medullary
enhancement when compared with normal controls
and patients with acute tubular necrosis. Four patients
with acute allograft rejection had superimposed acute
tubular necrosis, and MR renography was unable to
distinguish them from those who had acute allograft
rejection alone.
Although less common with newer immunosup-
pressive agents, cyclosporine Atoxicity can also cause
transplant dysfunction. Agildere et al [56] used a turbo
FLASH sequence with 2 mL of Gd-DTPA to obtain
cortical and medullary signal intensity curves for
studying the differences between acute allograft rejec-
tion and cyclosporine A toxicity in 17 renal transplant
patients. Although the sample size was small, results
showed abnormally low initial mean signal intensities
and low final mean steady-state signal intensities in
patients with acute allograft rejection compared with
those with cyclosporine A toxicity, likely attributable
to the conspicuous role that decreased cortical perfu-
sion plays in acute allograft rejection.
Functional studies also have proved useful in
diagnosing ureteral complications of renal transplan-
tation. Dorsam et al [57] evaluated the ability of
MR urography to diagnose such complications in
15 patients, 11 of whom had elevated serum creatinine
levels. In six patients whose MR urography exami-
Fig. 6. Renal transplant dysfunction in a 62-year-old man who underwent transplantation 10 weeks earlier. Conventional
contrast-enhanced three-dimensional T1- and T2-weighted imaging of the transplanted kidney showed (A) a patent arterial
anastomosis, (B) a patent venous anastomosis, and (C) a normal collecting system without ureteral obstruction or lymphocele.
Low-dose functional MR renography (dashed line, similar to the technique shown in Fig. 1) using 4-mL Gd-DTPA revealed
(D) normal cortical perfusion, (E) slightly delayed medullary enhancement, and (F) markedly diminished contrast excretion
when compared with MR renography performed 6 days after transplantation when renal function was normal (solid line). This
pattern of enhancement suggests the diagnosis of acute tubular necrosis rather than rejection [2]. This was confirmed by biopsy.
nations showed moderate hydronephrosis of the allo-
graft but no obstruction, subsequent clinical follow-up
revealed stable performance of the allograft.
Summary
MR imaging is the only single noninvasive test
that can potentially provide a complete picture of
renal status with minimal risk to the patient, simulta-
neously improving diagnosis while lowering medical
costs by virtue of its being a single test [49]. The
strengths of MR imaging lie in its high spatial and
temporal resolution and its lack of exposure to
ionizing radiation and nephrotoxic contrast agents.
This article reviews the use of MR imaging for
quantification of renal functional parameters and its
application to clinical problems, such as RVD, hydro-
Fig. 6 (continued).
nephrosis, and renal transplantation. Although advan-
ces in both the technical and clinical aspects of
functional renal MR imaging have been made, much
remains to be done. The preliminary results reported
in the many studies reviewed are exciting, but these
techniques need to be validated against accepted
standards where such standards exist. In addition,
and perhaps more important, the effects of these new
diagnostic methods on patient outcomes must be
studied. Finally, further progress in image processing
and analysis must be made to make functional renal
MR imaging truly practical. With these advances, one
can expect functional renal MR imaging to play an
ever-expanding and influential role in the care and
management of the patient with renal disease.
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Imaging of renal trauma
J. Kevin Smith, PhD, MD
*
, Philip J. Kenney, MD
Department of Diagnostic Radiology, University of Alabama at Birmingham Health System, 619 South 19th Street,
Trauma is nondiscriminatory and affects children,
adolescents, young adults, pregnant women, and the
elderly. Trauma is the second leading cause of years
of life lost for all Americans and the leading cause of
death and disability for youth and young adult
Americans. The financial cost of injuries in America
is estimated at more than $224 billion each year [1].
Despite advances in the technology of motor vehicle
safety, motor vehicle collision remains the most
common cause of blunt abdominal trauma in the
United States. Other less frequent sources of blunt
trauma to the abdomen include falls from a height,
assaults, bicycle accidents, and horseback riding
injuries. Renal injury is the most frequent urologic
trauma and occurs in up to 8% to 10% of patients
with significant blunt or penetrating abdominal trau-
ma; up to 80% of renal injuries are caused by blunt
trauma, mostly motor vehicle accidents, and most
significant renal injuries are associated with other
major organ injuries [2,3].
Care of the traumatized patient requires a multi-
disciplinary approach. The goal of trauma care is to
resuscitate the patient, to diagnose injuries, and to
implement appropriate therapeutic measures as quick-
ly as possible. Radiologists largely play a role in the
diagnosis and staging of injuries. Interventional radi-
ologists play an additional role in the management of
arterial injuries using angiography with transcatheter
embolization. To be an effective member of the
trauma team, the radiologist must be available for
emergent consultation, be adept at the imaging mo-
dalities used in the evaluation of the trauma patient,
and be familiar with those injuries sustained in blunt
abdominal trauma.
Current trends in trauma care are for less invasive
procedures and more conservative management of
many injuries, including renal injuries [2,4,5]. Better
resuscitation techniques, organization of dedicated
trauma centers, and faster response times are chang-
ing the way trauma surgeons evaluate patients. Im-
aging of trauma patients can help to determine which
patients can be managed conservatively and which
patients may require surgery, and to improve long-
term patient outcome.
Selection of patients to image
Most (95%) significant renal injuries are associated
with hematuria, but hematuria may be absent, espe-
cially with renal vascular injuries and ureteropelvic
junction (UPJ) avulsion or ureteral injuries [6,7]. Only
about 1 to 5 out of 1000 blunt trauma patients with only
microscopic hematuria and without hypotension have
significant urinary tract injury [811], so microhema-
turia alone is not an absolute indication for imaging.
At the authors institution abdominal and pelvic CT
is routinely used for blunt trauma patients with
abdominal symptoms, hypotension, or significantly
depressed level of consciousness. CT is used for
evaluation specifically of the genitourinary (GU) tract
for patients with gross hematuria; microscopic hema-
turia and hypotension; or patients with injuries asso-
ciated with renal injuries, such as lumbar spine, lower
rib, or transverse process fractures. Patients with pene-
trating trauma and any degree of hematuria undergo
urologic imaging. CT of all pediatric trauma patients
with any hematuria, even microscopic hematuria
doi:10.1016/S0033-8389(03)00075-7
* Corresponding author. N358 Jefferson Towers, De-
partment of Radiology, University of Alabama Hospital, 619
South 19th Street, Birmingham, AL 352496830.
E-mail address: jksmith@uabmc.edu (J.K. Smith).
Radiol Clin N Am 41 (2003) 10191035
alone, has traditionally been advocated but recent evi-
dence suggests an approach similar to adult trauma pa-
tients may be acceptable [12].
Imaging modalities
Radiography
Radiography is an important tool in the primary
evaluation of chest and skeletal trauma; however, its
use in the setting of blunt abdominal trauma is
virtually nonexistent. Previously described signs of
hemoperitoneum on radiography are not of sufficient
sensitivity or specificity to be useful. The widespread
availability of CT, and to some degree ultrasonogra-
phy (US), has replaced abdominal radiography in this
regard. Radiography does still play a role in the
setting of penetrating trauma to the abdomen.
Intravenous urography
Traditionally, genitourinary injury has been
assessed by intravenous urography (IVU), standard
cystography, and retrograde urethrography. With
ready availability of CT the IVU has taken a more
limited role because of its lower sensitivity for in-
jury, lesser sensitivity for urinary contrast extravasa-
tion, and lack of ability to detect nonurologic injuries
(Fig. 1) [13,14]. The IVU still may be used if CT
is not readily available, for unstable patients going to
surgery, or for urologic imaging if the patient is al-
ready in the operating room. This is typically per-
formed as a one-shot intravenous pyelogram, which
actually consists of a scout radiograph and typically
one film immediately after contrast injection and
another about 10 minutes after contrast injection.
Additional delayed films may be needed if there is
delayed excretion of contrast and to detect urinary
contrast extravasation. The IVP may demonstrate loss
of the renal outline or psoas shadow if there is
perinephric hemorrhage, diminished or nonexcretion
(Fig. 2), or contrast extravasation from an injured
kidney. The ureters should be visualized to evaluate
for ureteral injury or displacement and contralateral
functioning kidney confirmed if there is significant
renal injury, in the event the injured kidney may need
to be removed [5,15].
Fig. 1. (A) Ten-minute radiograph from a one-shot intravenous pyelogram on a patient involved in a motor vehicle collision
shows normal kidneys and ureters bilaterally. (B) Image from contrast CT of the abdomen shows a splenic laceration with active
contrast extravasation (arrow).
J.K. Smith, P.J. Kenney / Radiol Clin N Am 41 (2003) 10191035 1020
Ultrasound
The use of abdominal US in trauma patients
continues to be controversial; the use of US for
detection of renal and urologic injuries is particularly
problematic. US is able to detect free fluid in the
abdomen and pelvis but it cannot distinguish between
extravasated urine, blood, and other types of fluid, an
often clinically important distinction, and cannot
determine the source of bleeding. US is less sensitive
at depicting solid organ injury, especially of the
kidneys, depicting as few as 22% of renal injuries
[16,17]. Although significant renal injuries are often
associated with other abdominal injuries, isolated
renal injuries may not have associated peritoneal fluid
in as many as 65% of the cases (Fig. 3) [16]. In
addition, US is insensitive for retroperitoneal blood
and hollow organ injury [18].
Nevertheless, US has gained moderate acceptance
in the United States as a means to evaluate the patient
with blunt abdominal trauma. US in the setting of
trauma usually consists of a focused abdominal
sonography for trauma (FAST) scan. FAST scans
can be completed in several minutes during the
resuscitation of the patient in the trauma bay. The
primary goal of the FAST scan is the identification of
free fluid (hemoperitoneum) in the unstable patient, a
finding that usually prompts an exploratory laparot-
omy. The FAST scan usually consists of interrogation
of six locations for the presence of free fluid: (1) the
right upper quadrant including the hepatorenal recess,
(2) the left upper quadrant including the splenorenal
recess, (3 and 4) both paracolic gutters, (5) the pelvis
including its various peritoneal cavity recesses, and
(6) the pericardial space [19].
Various studies have proposed using US to search
for solid organ injury, but sufficient sensitivities and
specificities have not been demonstrated [2022].
US has also been used to screen all blunt abdominal
trauma victims as part of a management algorithm. In
some institutions, radiologists or sonologists perform
the US examination, but in many centers this task
falls to the trauma surgeon or emergency physician.
There is little satisfactory training for clinical US in
these specialties and virtually no training in the
technical aspects of US; the ability of such individ-
uals to perform quality examinations has been seri-
ously questioned. If trauma US is to be performed by
the radiology department, the service must be readily
available at all times.
Ultrasound may show renal laceration or a change
in echogenicity of the injured kidney, or a decrease in
the usual perinephric echogenicity if there is peri-
nephric fluid or hemorrhage. If US is negative and
there is significant hematuria, or if the US is positive,
CT is still indicated for better evaluation of the injury
if the patient is stable. For this reason the use of US is
probably best reserved for rapid evaluation for intra-
peritoneal fluid in the unstable patient who may
require urgent surgery.
Angiography
Before the widespread availability of CT, angiog-
raphy was often used to evaluate renal abnormalities
seen at IVU, especially suspected arterial injuries.
With the advent of faster CT scanners and their
increased detection of active arterial extravasation,
angiography is being used less frequently for the
initial diagnosis of traumatic injuries. CT shows
many injuries not seen at angiography and accurately
characterizes most vascular injuries. Even vascular
contrast extravasation is better depicted by CT. Con-
versely, the role of angiography in the management of
vascular and exsanguinating solid-organ injuries con-
tinues to increase given the emphasis on nonoperative
management of trauma patients. Angiography with
transcatheter embolization is becoming the standard
of care in the treatment of patients with many
vascular injuries. Angiographic embolization is well-
suited to treat traumatic pseudoaneurysms and active
arterial bleeding caused by splenic or hepatic and
sometimes renal injury, and hemorrhage associated
with pelvic ring injury [2325].
Fig. 2. Absent nephrogram. Ten-minute radiograph from a
one-shot intravenous pyelogram of a patient involved in a
motor vehicle collision shows no enhancement or contrast
excretion on the right.
Diagnostic peritoneal lavage
The diagnostic peritoneal lavage is not an imag-
ing modality but is the traditional gold standard for
evaluating for abdominal injury, and is safe and
rapid when performed by experienced surgeons.
Early studies showed diagnostic peritoneal lavage
to be faster and more rapid than CT, and many
showed diagnostic peritoneal lavage to have better
accuracy [2629]. With improvements in CT tech-
niques including dynamic and then helical scanning,
increased experience with CT, and location of CT in
close physical proximity to the trauma bay, however,
these differences have been erased [30]. For renal
injuries diagnostic peritoneal lavage, like ultrasound,
may be especially problematic because isolated renal
injuries may not be associated with intraperitoneal
fluid, and when positive the diagnostic peritoneal
lavage is not specific for the type of injury. Some
authors argue screening diagnostic peritoneal lavage
with selective use of CT is less expensive, but actual
cost analysis is lacking [31]. At the authors institu-
tion, there is a multidetector CT scanner in the emer-
gency department within a few feet of the trauma
bay and diagnostic peritoneal lavage is now infre-
quently performed.
Retrograde pyelography
Retrograde pyelography is primarily useful if
ureteral, UPJ, or renal pelvic injury is suspected
and delayed images were not obtained or were not
adequate to exclude these injuries on CT or IVU. It
is often not practical in the emergent evaluation of
the severely injured patient, however, and does not
characterize renal parenchymal injuries.
Fig. 3. Trauma ultrasound. (A) Ultrasound gray-scale image of a patient involved in a motor vehicle collision shows normal
right kidney. (B) Ultrasound image with power Doppler shows no blood flow within the right kidney. (C) Contrast-enhanced CT
image shows nonenhancing right kidney. Note relatively small amount of hemorrhage and the blind ending stump of the renal
artery (arrow).
Radionuclide renal scintigraphy
Radionuclide renal scintigraphy may be used to
evaluate the renal function of injured kidneys, eval-
uate perfusion of a kidney with demonstrated or
suspected arterial injury, and for evaluation of the
repaired kidney or renal vasculature. Since the wide-
spread availability of CT, renal scintigraphy is rarely
used in the acute setting.
MR imaging
MR imaging with gadolinium may be helpful to
assess or characterize renal injury in the stable patient
with strong contraindication for iodinated contrast,
but MR imaging is usually not practical in the acutely
severely injured patient because of motion artifacts
and the time often required.
CT
CT is the most comprehensive diagnostic tool
available for the evaluation of the victim of blunt
abdominal trauma. Unlike US and diagnostic perito-
neal lavage, which are limited to answering certain
specific diagnostic questions (eg, is there hemo-
peritoneum), CT affords a comprehensive evaluation
of all the intra-abdominal structures. One of the major
advantages of CT is its ability to stage injuries to the
abdomen. The trend toward greater nonoperative
management of traumatic abdominal injuries can be
attributed in large part to successful staging of inju-
ries by CT. It is desirable to have the CT scanner as
close to the trauma bay as possible to minimize pa-
tient transport time.
CT technique
Optimal evaluation of the blunt abdominal trauma
victim requires optimization of CT technique. Ade-
quate scans can be obtained on conventional axial CT
scanners, but helical CT scanners offer a substantial
gain in speed and quality. Multidetector CT scanners
have given the trauma radiologist an even more
powerful tool compared with single-slice helical CT.
Thin-section, high-quality images can be obtained in
a fraction of the time required for even helical single-
slice scanners. Shorter scan times mean less time for
motion and breathing artifact. Multidetector CT
allows for optimal detection of injuries, such as active
arterial contrast extravasation, while decreasing the
time that critically injured trauma patients are re-
quired to be in the CT scanner. Multidetector CT is
not only faster but also offers much more efficient use
of tube-heat capacity so that multiple, consecutive CT
examinations can be performed without having to
wait for the CT tube to cool.
Intravenous contrast is a necessity for satisfactory
accuracy in abdominal CT scans performed for trau-
ma. Solid organ injuries, such as liver, splenic, or
renal lacerations, can be unapparent on noncontrast
scans. Active arterial extravasation can only be
detected with the use of intravenous contrast. Low-
osmolality, nonionic contrast is preferred. A typical
contrast dose is 120 to 150 mL for adults and 1.5 to
2 mL/kg for children. An injection rate of at least
2 mL/second is desirable, but rates in the range of 3 to
4 mL/second provide optimal vascular and parenchy-
mal enhancement. Helical CT and multidetector
CT scanners have increased the frequency with which
active arterial extravasation can be detected.
Most authors favor the use of oral contrast in
trauma abdominal CT scans. Oral contrast is safe,
even in children [32,33]. Administration of oral
contrast can aid greatly in the detection of bowel
injuries. A dilute solution of 4% diatrizoate meglu-
mine in tap water is administered by mouth or by
nasogastric tube as soon as the abdominal CT is
requested. A volume of 400 to 600 mL is given.
For trauma patients the scan is not delayed for
passage of oral contrast through the bowel. In this
short time frame, usually only the stomach, duode-
num, and proximal jejunum are opacified. Fortunate-
ly, these are some of the most common sites of bowel
injury. Some authors suggest withdrawing the naso-
gastric tube into the distal esophagus during the scan
to reduce streak artifact in the upper abdomen.
Five millimeters or less image thickness is helpful
to avoid significant volume averaging artifacts. For
single-slice helical CT a scanner pitch of 1.5:1 is a
good compromise between speed and excessive slice
profile broadening. On a multidetector CT scanner
high-speed (pitch greater than one) scanning speeds
the image acquisition and still generally results in
excellent image quality. It may be helpful to scan at
less than the maximum table speed to allow retro-
spective reconstruction of thinner slices if needed for
subtle injuries or the evaluation of associated spine or
bony pelvic injuries. For example, on a General
Electric four-slice scanner the authors use HS mode
with 5-mm images and table speed of 15 mm per
rotation, 0.8-second scanning. This allows retrospec-
tive reconstruction of 2.5-mm thick slices if needed.
With the newer 16 or more slice scanners even the
fastest table speeds still allow reconstruction of very
thin slices if needed. Kilovolt (peak) is usually 140
and milliampere seconds between 100 and 300 de-
pending on scan mode and patient size. The acquisi-
tion start times after beginning contrast injections are
45 seconds for chest and 75 seconds for abdomen; a
pause of 180 seconds before scanning the pelvis al-
lows the bladder to opacify if a CT cystogram is not
going to be performed. Some centers routinely scan
through the kidneys a second time during the uro-
graphic phase of enhancement to detect subtle paren-
chymal and collecting system injuries. The authors
trauma patients images are routinely evaluated as
they are obtained while the patient is still on the CT
scanner and if there is significant perinephric or peri-
ureteral fluid, delayed images (10 to 15 minutes) are
obtained to evaluate for urinary contrast extravasation
Standard CT with intravenous contrast has been
shown to yield up to 40% false-negatives for bladder
injury. If bladder injury is a clinical concern (gross
hematuria or pelvic ring fracture), a cystogram or CT
cystogram should be performed. After the initial scan,
the patient can be evaluated by CT cystography
without having to move to another location. CT cys-
tography is equal to or better than conventional cys-
tography if adequate retrograde bladder distention is
achieved with dilute contrast and CT cystography is
capable of distinguishing intraperitoneal, extraperito-
Fig. 4. Renal contusion. Contrast-enhanced CT of a patient
in a motor vehicle collision with small, ill-defined wedge-
shaped area of slight hypoenhancement in the mid right
kidney (arrow).
Fig. 5. Subcapsular hematoma. Contrast-enhanced CTscan of
a patient involved in a motor vehicle collision demonstrates a
crescentic high-density fluid collection around the left kidney
(arrows). Note the relatively well-defined outer margin and
the deformity of the underlying renal parenchyma.
Fig. 6. Perinephric and subcapsular hematomas. Contrast-
enhanced CT scan of a patient involved in a motor vehicle
collision shows an ill-defined high-density fluid collection
in the perinephric space (arrows). This patient also had a
subcapsular hematoma with deformity of the renal paren-
chyma (arrowheads).
Fig. 7. Grade 23 renal injury: renal laceration. Contrast-
enhanced CT scan of a patient involved in a motor vehicle
collision shows slightly irregular low-attenuation defect in
the anterior left kidney with associated perinephric fluid.
neal, or combined bladder rupture [34]. For CT
cystography, once the abdominal CT scan is com-
plete, the urinary bladder is drained by Foley catheter.
The bladder is then filled by gravity infusion with
dilute iodine-based contrast (12 mL of 300-strength
contrast in 500 mL normal saline) and the pelvis
scanned again when the bladder is fully distended
taking care to include the entire urinary bladder.
Trauma patients with histories consistent with
urethral trauma, gross blood at the urethral meatus,
or high-riding prostate gland on physical examination
should undergo a retrograde urethrogram before
placement of a Foley catheter. Patients with a lower
index of suspicion can undergo a pericatheter urethro-
gram at a later time and a catheter is generally placed
during the initial assessment in the trauma bay.
CT interpretation
Thoroughness and attention to detail are of vital
importance in the interpretation of CT scans for blunt
Fig. 8. Grade 3 renal injury: renal laceration. (A) Contrast-enhanced portal venous phase image froma CTscan of a patient involved
in a motor vehicle collision has an irregular nonenhancing renal parenchymal defect in the mid lateral left kidney with associated
perinephric hematoma. (B) Delayed image from the same CT scan shows no urinary contrast extravasation.
Fig. 9. Grade 4 renal injury: renal laceration into collecting system. (A) Tiny amount of fluid medial to the renal pelvis (arrow)
was the only clue to this laceration involving the collecting system. (B) Delayed image from the same CT shows a tiny area of
urinary contrast extravasation (arrow).
abdominal trauma. A complete evaluation of a trauma
CT involves viewing the entire scan with three dif-
ferent window-level settings: (1) soft tissue, (2) lung,
and (3) bone. Immediate life-threatening injuries
should be sought first: large hemoperitoneum, large
or tension pneumothorax, pneumoperitoneum, signs
of hypovolemic shock, and active arterial extravasa-
tion. Each area of the abdomen and pelvis should
then be interrogated for the presence of injury: liver
and right paracolic gutter; spleen and left paracolic
gutter; upper abdominal organs including the stom-
ach, duodenum, pancreas, gallbladder, and biliary
tree; retroperitoneum including the adrenals, kidneys,
inferior vena cava, and aorta; small bowel, colon, and
mesentery; pelvis including the urinary bladder;
muscles including the abdominal wall, psoas, iliacus,
and gluteals; bones including the spine and pelvis;
and thighs (looking for soft tissue hematoma). West
[35] describes this systematic review as the every-
organ-on-every-slice approach. The authors believe
image review on the modern PACs workstation is
best done by paging relatively rapidly through the
images multiple times, paying specific attention to a
specific organ during each pass through the images.
The authors prefer to describe this approach for
image review as every-slice-of-every-organ.
Classification of renal injuries
Renal injuries are graded by the American Asso-
ciation for the Surgery of Trauma according to the
Fig. 10. Grade 4 renal injury: lacerations extending into the collecting system. (A) Contrast-enhanced CT scan of a patient
involved in a motor vehicle collision shows several deep lacerations into the collecting system (arrows). (B) Delayed image from
the same CT scan shows urinary contrast extravasation (arrow).
Fig. 11. Grade 4 renal injury: segmental infarctions. (A) Contrast-enhanced CT scan of a patient involved in a motor vehicle
collision shows well-defined, wedge-shaped, nonenhancing areas in the mid left kidney. (B) Follow-up contrast-enhanced CTscan
of the same patient shows complete resolution of the findings in about 2 weeks.
depth of the injury and involvement of vessels or the
collecting system as follows[36]:
Grade 1
Hematuria with normal imaging studies
Contusions
Nonexpanding subcapsular hematomas
Grade 2
Nonexpanding perinephric hematomas con-
fined to the retroperitoneum
Superficial cortical lacerations less than 1 cm
in depth without collecting system injury
Grade 3
Renal lacerations greater than 1 cm in depth
that do not involve the collecting system
Grade 4
Renal lacerations extending through the kid-
ney into the collecting system
Injuries involving the main renal artery or vein
with contained hemorrhage
Segmental infarctions without associated lac-
erations
Grade 5
Shattered or devascularized kidney
UPJ avulsions
Complete laceration or thrombus of the main
renal artery or vein
These scores were devised principally to facilitate
clinical research, but the radiologist should be familiar
with the scoring system because it is part of the
language of evaluation and triage use by the trauma
surgeon. In general the American Association for
the Surgery of Trauma injury grade correlates with
the perceived need for surgery to repair or remove the
injured kidney [37]. Even with high-grade injuries,
Fig. 12. Grade 4 renal injury: infarctions and associated
laceration. Contrast-enhanced CT scan of a patient involved
in a motor vehicle collision shows well-circumscribed,
wedge-shaped areas of nonenhancement posteromedially in
both kidneys (arrows). The right kidney has associated
laceration and hematoma. Note also the peritoneal fluid and
bowel edema (shock bowel).
Fig. 13. Grade 5 renal injury: infarctions and multiple deep lacerations. (A) Contrast-enhanced CT scan of a patient involved in a
motor vehicle collision shows a well-defined, wedge-shaped, nonenhancing infarction (arrow) and several deep, irregular,
nonenhancing lacerations. (B) Delayed image from the same CT scan has contrast extravasating medially and laterally from the
deep lacerations.
however, nonoperative management may be success-
ful or even preferred in stable patients because renal
function is often better preserved with nonoperative
management [5,38]. Unless there is extensive devital-
ized tissue, active hemorrhage, a large injury to the
collecting system, or ureteral disruption, renal injuries
are often managed conservatively [39,40].
Grade 1 injuries
American Association for the Surgery of Trauma
grade 1 renal injuries account for about 80% of renal
injuries and include hematuria with normal imaging
studies, contusions, and nonexpanding subcapsular
hematomas. Contusions are seen as either ill-defined
Fig. 14. Grade 5 renal injuries: shattered kidney with venous injury managed conservatively. (A) Contrast-enhanced CTscan of a
patient involved in a motor vehicle collision demonstrates nearly occlusive thrombus in the right renal vein (arrow). (B) A slightly
lower image from the same CT scan has multiple deep, irregular hypodense lacerations extending through the renal parenchyma
with hematoma within the lacerations and around the kidney and devitalized segments of renal parenchyma (arrow). (C) Delayed
image fromthe same CTscan shows faint residual area of vascular contrast extravasation (arrow), which is much less dense than the
adjacent ureteral contrast. (D) Follow-up contrast-enhanced CTscan on the same patient. The kidney is deformed but the renal vein
injury and the urinary leak resolved and there is considerable residual functioning renal parenchyma.
or sometimes sharply marginated areas of decreased
enhancement and excretion. They are distinguishable
from segmental infarctions by the presence of en-
hancement (Fig. 4). Subcapsular hematomas are less
common in blunt trauma than perinephric hematomas
and show up as an often high-density fluid collection
contained between the renal parenchyma and the
renal capsule, frequently with some deformity of
the underlying kidney. When small they may be
crescentic (Fig. 5), but larger collections may become
elliptical and compress the renal parenchyma (Fig. 6).
Rarely, the collection may compress the kidney
enough to decrease the renal perfusion and result in
reactive hypertension, the so-called Page kidney.
Grade 2 and 3 injuries
Grade 2 injuries include nonexpanding perinephric
hematomas confined to the retroperitoneum and
superficial cortical lacerations less than 1 cm in depth
without collecting system injury. The perinephric
hematoma may be an isolated injury but is often
associated with underlying renal injury. It manifests
on CT as a typically ill-defined, often high-density
fluid collection between the renal parenchyma and
Gerotas fascia (see Fig. 6). The presence of a peri-
nephric hematoma should prompt a thorough search
for an underlying renal injury. A perinephric hema-
toma may be quite large, but traditionally does not
deform the kidney as opposed to the typical sub-
capsular hematoma, which often does deformthe renal
contour when large.
Renal lacerations appear as irregular or linear
parenchymal defects, which may contain blood or
clot, and may be higher than water density but are
without enhancement. Grade 2 lacerations are defined
as less than 1 cm in depth and without involvement of
the collecting system (Fig. 7), and have no urinary
contrast extravasation. Grade 3 renal injuries include
similar renal lacerations that are greater than 1 cm,
but do not involve the collecting system (Fig. 8).
Grade 1 to 3 renal injuries are almost always man-
aged conservatively unless there is brisk active hem-
orrhage [39,40]. Active hemorrhage may be managed
successfully with selective catheter embolization if
the patient is otherwise stable [41,42].
Grade 4 injuries
Renal lacerations extending through the kidney
into the collecting system or injuries involving the
main renal artery or vein with contained hemorrhage
are classified as grade 4. Lacerations involving the
collecting system frequently lead to extravasation of
urine and urinary contrast; any time there are lacer-
ations extending through the kidney or significant
perinephric fluid, especially around the renal hilum,
delayed images should be obtained to evaluate for
urine extravasation (Figs. 9, 10). Even large urinary
extravasations often resolve with conservative treat-
ment, but stenting may be helpful with larger leaks. If
there is significant devitalized renal tissue, especially
with concomitant intraperitoneal injuries, in addition
to the urine leak, surgical debridement or repair may
be needed to prevent later development of urinoma
and infection or abscess formation, which may ne-
cessitate nephrectomy to prevent sepsis [4].
Fig. 15. Grade 5 renal injury: ureteropelvic junction avulsion. (A) Five-minute film from an intravenous pyelogram on a patient
involved in a motor vehicle collision shows relatively minor calyceal blunting on the left. (B) Ten-minute film shows progressive
accumulation of urinary contrast adjacent to the blind ending proximal ureter. The lack of contrast in the more distal ureter
suggests a complete tear.
Segmental infarctions without associated lacera-
tions are also grade 4 injuries. Segmental infarctions
may occur because of thrombosis, dissection, or lac-
eration of segmental arteries and are often associated
with other renal injuries. They manifest as well-
circumscribed, linear or wedge-shaped, often multi-
focal nonenhancing areas extending through the renal
parenchyma in a radial or segmental orientation
(Figs. 11, 12). They usually resolve spontaneously
(see Fig. 11) or result in relatively minor renal scaring
and are treated conservatively [43,44]. Rarely hyper-
tension may develop as a delayed complication in
6% to 20% of patients but often resolves or can be
medically managed [25,45].
Grade 5 injuries
Injuries resulting in a shattered or devascularized
kidney, UPJ avulsions, and complete laceration or
thrombosis of the main renal artery or vein are
classified as grade 5 renal injuries. A shattered kidney
is basically the extreme of multiple renal lacerations,
Fig. 16. Grade 5 renal injury: ureteropelvic junction avulsion. (A) Contrast-enhanced CT of a patient involved in a motor vehicle
collision has a small amount of medial perinephric fluid (arrows). (B) Delayed image from the same CT scan shows medial
perinephric urinary contrast extravasation and no contrast in the more distal ureter.
Fig. 17. Grade 5 renal injury: ureteropelvic junction avulsion. (A) Contrast-enhanced CT of a patient involved in a motor vehicle
collision has a moderate perinephric fluid collection (straight arrows) and minimal medial perinephric fluid (white arrow).
(B) Delayed images of the same CT scan demonstrate urinary contrast extravasation and lack of opacification of the distal ureter.
and there are often devitalized areas caused by
concomitant infarction, and urinary extravasation
caused by associated injuries to the collecting system
(Figs. 13, 14).
Injury of the UPJ occurs because of shearing
stress at the renal pelvis; during rapid deceleration
or hyperextension the kidney pulls on the relatively
fixed ureter and renal artery and vein. The UPJ injury
may be complete avulsion or partial tear. Both ex-
hibit characteristic medial or circumrenal urinoma
(Figs. 1517) [4648]. The partial tear may be dis-
tinguished from the complete avulsion by the pres-
ence of contrast in the distal ureter [47]. Hematuria is
often absent [47,49]. Complete tears require surgical
Fig. 18. Grade 5 renal injury: missed ureteropelvic junction avulsion. (A) Contrast-enhanced CT on a patient after motor vehicle
collision shows a small amount of medial perinephric fluid (arrows). The significance of the finding was not appreciated, so
delayed images were not obtained. (B) Follow-up contrast-enhanced CT scan of the same patient shows interval development of
hydronephrosis and a large urinoma (arrows). (C) Percutaneous nephrostogram on the same patient shows interruption of the
ureter at or just below the ureteropelvic junction with extravasation of urinary contrast and no filling of the distal ureter. A
nephrectomy was eventually performed because of infection of the urinoma.
repair, but some partial tears may resolve with stent-
ing or observation. If the diagnosis is missed and the
proximal collecting system is not drained, urinoma
may form and nephrectomy may be needed (Fig. 18).
A devascularized kidney most commonly results
from an incomplete vascular tear with thrombosis
involving the main renal artery. Hematuria is often
absent, especially if there are not other associated
injuries [50]. The kidney is nonenhancing, and there
may be little hematoma or other sign of injury (see
Fig. 3; Fig. 19). The blind ending renal artery is
sometimes seen and there may be retrograde opacifi-
cation of the renal vein or cortical rim sign, which may
not be apparent early [51]. More rarely, there is
complete tear of the artery with massive hematoma
or active bleeding. These injuries are often associated
with other renal injuries and this contributes to poor
renal outcome of attempted repair so the management
is usually expectant for stable patients or nephrectomy
if there is active bleed or major parenchymal disrup-
tion, unless there is injury or absence of the contralat-
eral kidney [50,52]. Hypertension may develop as a
delayed complication weeks to months after the injury
in as many as 40% to 50% of patients; often the
hypertension resolves or can be managed medically
but occasionally nephrectomy is required [50,52].
Injuries to the main renal vein are another less
common form of vascular pedicle injury. There may
be thrombosis with CT typically showing filling
defect (see Fig. 14A) or nonenhancement of the vein
and delayed or persistent nephrogram with complete
occlusion [46,53]. Laceration of the renal vein
presents with medial or circumrenal subcapsular or
perinephric hematoma.
Vascular contrast extravasation
Bright enhancement close to the density of nearby
arteries within a laceration or around an injured
kidney during the early phases of CT scanning
indicates either contained or active hemorrhage. A
contained hemorrhage or pseudoaneurysm is fairly
well circumscribed and contained within the renal
Fig. 19. Grade 5 renal injury: main renal artery. Contrast-
enhanced CT on a patient in a motor vehicle collision with
nonenhancing right kidney. Note the relative lack of peri-
nephric fluid. There was no hematoma.
Fig. 20. Active vascular contrast extravasation. Contrast-
enhanced CT on a patient in a motor vehicle collision with a
tiny renal laceration, but with large subcapsular and peri-
nephric hematomas and waterfall- shaped extravasation of
vascular contrast into the hematoma (arrow).
Fig. 21. Active vascular contrast extravasation. Contrast-
enhanced CT on a patient in a motor vehicle collision with a
small renal laceration, but with large subcapsular and peri-
nephric hematomas and flame-shaped extravasation of vas-
cular contrast into the hematoma (arrow).
parenchyma or laceration. Active hemorrhage is ill-
defined or flame- or waterfall-shaped, with an asso-
ciated fresh hematoma, which often shows dependant
or circumferential layering of older and fresher hem-
orrhage (Figs. 20, 21). As with other organs, active
extravasation of arterial contrast from the main renal
artery or lacerated kidney may indicate the need for
urgent surgery or transcatheter embolization to pre-
vent exsanguination [5458].
Pseudoaneurysms may persist or enlarge and may
occasionally cause delayed bleeding or rarely hyper-
tension. Arteriovenous fistulas associated with renal
lacerations from blunt or especially penetrating trau-
ma may be unapparent initially but may enlarge over
time, also potentially causing delayed bleeding, hy-
pertension, or high-output cardiac failure.
Summary
Trauma is a major cause of death and disability
and renal injuries occur in up to 10% of patients
with significant blunt abdominal trauma. Patients
with penetrating trauma and hematuria, blunt trau-
ma with shock and hematuria, or gross hematuria
warrant imaging of the urinary tract specifically and
CT is the preferred modality. If there is significant
perinephric fluid, especially medially, or deep lacer-
ation, delayed images should be obtained to evaluate
for urinary extravasation. Most renal injuries are
minor, including contusions, subcapsular and peri-
nephric hematoma, and superficial lacerations. More
significant injuries include deep lacerations, shattered
kidney, active hemorrhage, infarctions, and vascular
pedicle and UPJ injuries. These injuries are more
likely to need surgery or have delayed complications
but may still often be managed conservatively. The
presence of urinary extravasation and large devi-
talized areas of renal parenchyma, especially with
associated injuries of intraperitoneal organs, is par-
ticularly prone to complication and usually requires
surgery. Active hemorrhage should be recognized
because it often indicates a need for urgent surgery
or embolization to prevent exsanguination.
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Imaging of hereditary renal cancer
Peter L. Choyke, MD
Department of Radiology, Imaging Sciences Program, National Institutes of Health, NIH Building 10, Room 1C660,
Bethesda, MD 208921182, USA
Renal cancer is diagnosed in over 30,000 Ameri-
cans each year and accounts for approximately
12,000 annual deaths. Smoking, obesity, and occu-
pational exposures have been implicated in the
development of renal cancers but, in general, the
cause of renal cancer remains obscure [1]. Although
hereditary renal cancer makes up only approximately
4% of the total number of cases, this number is
expected to grow as a more complete understanding
of the genetic causes of cancer is elucidated [2]. As
hereditary renal cancer syndromes become better
understood, they provide insights into the mecha-
nisms of cancer development in the general popula-
tion and assist efforts to prevent and treat renal
cancers (Table 1).
The most common cell type of renal cancer is the
clear cell carcinoma, followed by papillary (types I
and II), chromophobe carcinoma and oncocytoma
[3,4]. Medullary carcinoma and duct of Bellini can-
cers are rare renal tumors. Over the past 5 years,
hereditary renal cancer syndromes have been asso-
ciated with one or more of these cancer cell types.
The genes responsible for these syndromes have been
discovered in many cases and research is now under-
way to explain the molecular pathways leading to
tumor development. A more complete picture of the
mechanisms underlying the development of tumors of
varying cell types is emerging.
Over the past decade substantial progress has been
made in the understanding of the genetic basis of
cancer in humans. This article reviews the current
state-of-the-science of hereditary renal cancers with
particular attention to their imaging features and
clinical management.
Histologic subtypes of renal cancer
Before considering the individual hereditary renal
cancer syndromes it is important to review the char-
acteristics of the different cell types of renal cancer.
Renal cancers can be subclassified into a variety of cell
types (Fig. 1) [5]. Clear cell carcinomas are the most
frequent type of renal cancer accounting for approxi-
mately 75% of renal cancers. The term clear cell
carcinoma encompasses the clear cell variant, the
granular cell variant, and mixed cell types. The high
glycogen content within the cytoplasm of clear cell
cancer cells accounts for their lucent appearance on
conventional histologic stains. When glycogen is less
abundant, the cytoplasm is darker and the cells are
termed granular. A delicate but rich and permeable
vascular supply is often seen throughout these tumors,
although regions of necrosis, fibrosis, or hemorrhage
are avascular or hypovascular. Clear cell carcinomas
are thought to arise from the proximal tubular epithe-
lium of the kidney
The second leading type of renal cancer is termed
papillary, also sometimes called chromophil
renal cancer, which accounts for 10% to 15% of
all renal cancers. There are two subtypes of papillary
renal cell carcinomas, type I and type II, which are
distinguished by tumor architecture and cellular
morphology. Both types share a common papillary
structure: a fibrovascular core with tumor cells lining
the surface of each papilla (see Fig. 1) [5,6]. Type I,
or basophilic renal cancer, usually is considered
clinically low grade and has a favorable prognosis.
This tumor is composed of fronds of fibrovascular
papillary and tubular structures covered by cells with
scanty cytoplasm and small oval nuclei. Foamy
macrophages, which are thought to represent a host
immune response, are often present within the inter-
doi:10.1016/S0033-8389(03)00068-X
E-mail address: pchoyke@nih.gov
Radiol Clin N Am 41 (2003) 10371051
Table 1
The hereditary renal cancers in adults
Syndrome
Genes gene name
(gene Product)
Frequency of
renal cancer (%)
Predominant renal
tumor cell type
Other renal
tumor cell types Associated abnormalities
von-Hippel Lindau 3p26 VHL (pVHL) 2845 Clear cell Cysts CNS hemangioblastomas, retinal
angiomas, pancreatic cysts,
neuroendocrine tumors of pancreas,
pheochromocytoma
Tuberous sclerosis 9q34 TSC1 (hamartin) 16p13
TSC2 (tuberin)
12 Clear cell Cysts, angiomyolipoma,
papillary, chromophobe,
oncocytoma
CNS tubers, angiofibromas of skin,
cardiac rhadomyomas
Hereditary papillary
renal cancer
7q34 c-MET (HGF receptor) 19 Papillary type1 None
Hereditary leiomyoma
renal cell carcinoma
1q42-43 FH (fumarate hydratase) 1530 Papillary type 2 None Cutaneous and uterine leiomyomas
Birt-Hogg-Dube` 17p11.2 BHD (folliculin) 815 Chromophobe
oncocytic neoplasm
Clear cell,
papillary, oncocytoma
Fibrofolliculomas, lung cysts,
pneumothoraces
Familial renal oncocytoma Unknown Unknown Oncocytoma None Renal dysfunction
Medullary carcinoma
of the kidney
11p Unknown Medullary carcinoma None Sickle cell trait
P
.
L
.
C
h
o
y
k
e
/
R
a
d
i
o
l
C
l
i
n
N
A
m
4
1
(
2
0
0
3
)
1
0
3
7
1
0
5
1
1
0
3
8
stitium and psamma bodies also are frequently
present. Despite the apparent vascularity on his-
tology, type I papillary renal tumors typically enhance
poorly on CT or during renal angiography. Type II
papillary tumors, or eosinophilic renal cancers, bear a
superficial resemblance to type I tumors in that the
basic frond-like architecture is present but they may
not be related at a biologic level. Type II papillary
renal cancers consist of papillae covered by large
cells with abundant eosinophilic cytoplasm and large
nuclei with prominent nucleoli. Type II papillary
tumors often are more clinically aggressive than type
I papillary tumors and can enhance more intensely.
Papillary tumors also are thought to arise from the
proximal tubular epithelium
The chromophobe carcinoma, so-named because
of its lack of staining with typical histologic stains,
such as hematoxylin and eosin, is the third most
common type of renal cancer accounting for about
5% of renal tumors. Chromophobe carcinoma can be
stained with Hales colloidal iron, which yields a
homogeneous blue cytoplasmic stain [7]. In routine
histologic sections the cytoplasm tends to condense
near the cell membrane producing a halo around the
nucleus. The cytoplasm is rich in mitochondria
much like the oncocytoma [8]. The oncocytoma
itself is considered a benign renal neoplasm; how-
ever, this categorization has been called into
question by the resemblance of oncocytoma to chro-
mophobe carcinoma and by reports of metasta-
sizing oncocytomas [911]. Oncocytomas are
comprised of cells with abundant eosinophilic cyto-
plasm that are filled with mitochondria accounting
for the brown color on gross pathology. When they
are numerous the term oncocytosis is used and
can be seen in patients with chromophobe carcino-
mas [11]. Chromophobe carcinomas and oncocyto-
mas are thought to arise from intercalated cells in
the distal tubules.
Collecting duct carcinoma includes the medullary
renal cancer associated with sickle cell trait and duct
of Bellini tumors. Medullary renal cancer is charac-
terized histologically by irregular channels lined by
highly atypical epithelium that sometimes have a
hobnail appearance. The channels are found in an
inflamed desmoplastic stroma. [12,13]. Both medul-
lary renal cancer and duct of Bellini tumors are
clinically aggressive neoplasms. Medullary renal can-
cer and its variants arise from the collecting ducts,
which are histologically and embryologically distinct
from the tubular epithelium.
In the following sections the relationship between
each of the preceding cell types of renal cancer and its
corresponding genetic syndrome are described.
Von Hippel-Lindau disease
Von Hippel-Lindau disease (VHL) is a multisys-
tem autosomal-dominant hereditary disorder charac-
terized by the formation of hemangioblastomas in
the spine and posterior fossa, retinal angiomas,
pheochromocytomas, pancreatic cysts, cystadenomas
and neuroendocrine tumors, epididymal and broad
ligament cystadenomas, and renal cysts and tumors.
VHL gives rise to a variety of renal cystic lesions
ranging from pure cysts to mixed solid and cystic
masses to purely solid clear cell carcinomas of the
kidney. The VHL gene, found at 3p25, is considered
an important housekeeping or tumor suppressor gene
that in its normal state functions to prevent the
development of renal cancers. Mutations or inactiva-
tion of the VHL gene are found in over 60% of
sporadic clear cell renal carcinomas indicating that it
is one of the crucial genes in the development of clear
cell carcinoma of the kidney [14,15].
A tumor suppressor gene normally functions to
decrease the chance of developing cancer. When a
tumor suppressor gene is mutated and the resulting
protein product is abnormal, however, the affected
cells are at increased risk of malignancy. Tumor
development requires that both copies of the gene
become mutated or deleted. Unlike other diseases in
which more than one genetic locus has been impli-
cated, VHL seems to be caused by mutations at a
single gene locus, 3p25 (short arm of third chromo-
some). The gene was first discovered in 1993 by Latif
et al [16]. Subsequently it has been demonstrated that
the VHL gene codes for a protein, pVHL. One of the
normal roles of pVHL is to assist in the degradation of
an intracellular growth factor known as hypoxia
inducible factor (HIF) [17]. HIF is an important
regulator of metabolism and is dependent on the
oxygen tension within a cell. Normally, HIF is pro-
duced when the cell is exposed to hypoxic conditions.
Once normal oxygen tension is restored, HIF is
quickly degraded in a process mediated by pVHL.
For the pVHL protein to interact with HIF and
mediate its degradation, it must first bind other sig-
naling intermediaries known as elongin b and c and
Cul2 [18]. These molecules normally bind to pVHL
allowing pVHL to bind to HIF, allowing ubiquitina-
tion (ie, degradation) of HIF. The defective pVHL
protein is unable to bind to these smaller molecules or
binds only weakly. As a consequence HIF is not
degraded even in normoxic conditions. The cell acts
as if it were chronically hypoxic even under normoxic
conditions. HIF also mediates the production of a
number of downstream growth factors. These include
vascular endothelial growth factor, which is one of the
P.L. Choyke / Radiol Clin N Am 41 (2003) 10371051 1039
critical growth factors in early tumor angiogenesis.
Vascular endothelial growth factor has been a target
molecule for the first generation of antiangiogenic
treatments. One of the mechanisms of tumor devel-
opment in VHL may be the failure of pVHL to
suppress HIF leading to unregulated production of
vascular endothelial growth factor and angiogenesis.
[14,19]. Unregulated vascular endothelial growth fac-
tor may account for the highly vascular nature of clear
cell tumors of the kidney. HIF also stimulates the
production of erythropoietin, glucose transporters
(GLUT1), and nitric oxygen synthase. This could also
explain why some tumors in VHL produce excess
erythropoietin. Interestingly, when antibodies to vas-
cular endothelial growth factor were administered to
patients with VHL in a clinical trial, erythrocytosis
secondary to erythropoietin overproduction was
observed [20,21]. By blocking one pathway (vascular
endothelial growth factor), another (erythropoietin)
was overexpressed.
Avariety of mutations of the VHL gene have been
discovered including complete and partial deletions,
single missense mutations, and frame shift mutations.
Fortunately, patients suspected of the disease can now
be tested for VHL with a simple blood sample. DNA
from peripheral white cells is used to check for
recorded mutations in VHL. The test is 99% accurate
for the diagnosis of VHL [22].
Renal lesions are a common manifestation of
VHL. Between 60% and 70% of patients develop
cysts in the kidney and about 40% develop radio-
logically evident renal cancers (Fig. 2). If one exam-
ines the normal-appearing tissue of a kidney from a
patient with VHL one finds hundreds of small tumor-
lets scattered throughout the parenchyma, invisible to
the naked eye (Fig. 3) [23]. That only a few of many
tumors grow to visible tumors on CT is one of the
unusual features of VHL. Tumors can take many
forms in VHL. They can appear as cysts, cystic renal
cancers, and solid renal cancers [24]. The cell lining
of even a simple renal cyst in VHL contains clear
cells similar in appearance to those found within clear
cell carcinomas.
Cysts can regress or grow. The solid components
of mixed lesions tend to grow over time, whereas the
cystic areas remain unchanged or regress. Solid
lesions tend to grow progressively [25]. Occasionally,
heavily calcified or hemorrhagic cystic disease is
seen. Both are usually associated with less aggressive
forms of renal cancer but this is not universally true.
Fig. 1. The cell types of renal cancer. (A) Clear cell carcinoma. (B) Type I papillary renal cancer. (C) Type II papillary renal
cancer. (D) Chromophobe carcinoma. (E) Oncocytoma.
Renal cancers in VHL tend to be well differen-
tiated or Furman grade I to II when they are under
3 cm in diameter. Only one report of a metastatic
renal tumor less than 3 cm in diameter (2.5 cm) has
appeared in the literature [26]. As a consequence, it is
generally believed that treatment should be reserved
for patients with larger lesions, greater than or equal
to 3 cm in diameter. This strategy has been very
successful in preserving renal function while avoid-
ing metastatic disease [27,28].
Renal cancers are typically detected and measured
on serial contrast-enhanced CT scans (see Fig. 2).
Using multidetector CT, unenhanced images through
the liver and kidneys are first obtained with 5-mm
collimation. A bolus of intravenous iodinated contrast
(130 mL of a nonionic contrast agent) can be adminis-
tered at 3 mL/second and 2.5-mm thick sections
(reconstructed at 5-mm intervals) are obtained during
the arterial phase (approximately 25 seconds) and
during the venous phase (approximately 80 seconds).
The precontrast scans are useful for judging whether
a lesion is actually enhancing and are of particular use
when a hemorrhagic cyst is present. Arterial phase
images are useful for detecting pancreatic neuro-
endocrine tumors (found in approximately 10% to
15% of VHL patients), which enhance intensely only
on the arterial phase, whereas the venous phase is the
most important phase for evaluating the kidneys. The
adrenals are equally well seen on all three phases.
Three-dimensional CT angiography and reconstruc-
tion can also be performed as clinically necessary
before surgery where a three-dimensional model of
the kidney can be made to assist the surgeon in
identifying lesions for removal.
Serial CT imaging is recommended for patients
with VHL even if they have minimal or no renal
disease. The lifetime risk of renal cancer is high in
VHL and the key to preserving renal function and
preventing metastatic disease is careful monitoring of
Fig. 3. Clear cell tumorlet in the parenchyma of a patient
with von Hippel-Lindau disease. Note that there is a tiny
focus of tumor within the renal parenchyma (arrow).
Hundreds of these lesions are found in the kidneys of
patients with VHL.
Fig. 2. (A, B) Von Hippel-Lindau disease. This 32-year-old
man has bilateral solid and cystic renal masses. The solid
lesions proved to be clear cell carcinomas.
the patient [29]. Patients with minimal disease can be
scanned at 1- to 2-year intervals, whereas patients
with active renal tumors need to be seen more fre-
quently (every 6 to 12 months). In patients with
lesions of borderline size (approximately 3 cm) even
more frequent studies may be performed. Tumor
growth is not always linear and predictable and for
this reason the record of past CTs is not necessarily
predictive of the future for any given lesion. CT is the
preferred method of screening because it is relatively
less expensive than MR imaging and the appearance
of renal masses is well understood. MR imaging with
gadolinium chelate enhancement is a viable alterna-
tive in patients with poor renal function, those wishing
to avoid ionizing radiation, or severe allergy to iodin-
ated contrast media. This should be performed with a
torso array coil and fat suppression. Attempts should
be made to measure the lesion before and after
contrast using the same parameters [30]. Ultrasound
is less accurate than other techniques for detecting and
characterizing renal masses in VHL and should not be
relied on exclusively [31].
Why wait to treat known tumors within the
kidney in a patient with VHL? This is a conscious
strategy based on the knowledge that VHL is a
lifelong disorder that must be managed differently
than sporadic disease [28]. Preservation of renal
function must be balanced against the risk of meta-
static renal cancer. Partial nephrectomy is the method
with the longest track record. Unfortunately, with
every partial nephrectomy there is inevitably some
loss of renal function and scarring, which makes
subsequent surgeries even more difficult. As a con-
sequence, surgeries should be spaced as far apart
from each other as possible in the hopes of pre-
serving renal function for the longest possible inter-
val. It is recommended that partial nephrectomies not
be performed until the solid component of the largest
tumor is 3 cm or more.
The standard method of treatment of renal tumors
in VHL is nephron-sparing surgery [27]. In this
procedure, the surgeon enucleates visible tumors
and cysts on the renal surface. Deeper lesions are
detected using intraoperative ultrasound (Fig. 4) [32].
The purpose of the nephron-sparing approach is
to remove the relevant lesions while maximally pre-
serving renal parenchyma. Of course, there is a limit
to the number of procedures that can be performed on
a single kidney and completion nephrectomies are
sometimes necessary. If the patient is discovered too
late for nephron-sparing approaches, a total nephrec-
tomy may be necessary.
Recently, radiofrequency ablation and cryotherapy
have been used because they are comparatively
minimally invasive methods for treating small renal
cancers in VHL and other hereditary renal masses
[3335]. For lesions positioned close to the bowel,
laparoscopically guided radiofrequency ablation or
cryotherapy can be performed (Fig. 5) [3638].
Although no studies documenting improved survival
or enhanced renal function have been reported, it
seems reasonable that these approaches result in less
damage to the kidney. Because the tumor is not
treated under direct vision, however, it also is
possible that the tumor may be incompletely treated.
For this reason close follow-up with imaging studies
of treated lesions is important after radiofrequency
ablation or cryotherapy [37,38]. It is important to
realize that an untreated remnant of tumor measur-
ing 5 mm in diameter from a tumor that was
originally 3 cm behaves biologically like a 3-cm
lesion and not a 5-mm tumor. As a consequence,
early retreatment of recurrences is recommended.
Although radiofrequency ablation and cryotherapy
are attractive alternatives, long-term experience is
still lacking.
Hereditary papillary renal carcinoma
Hereditary papillary renal cancer (HPRC) is an
autosomal-dominant hereditary condition in which
the kidneys develop multiple, bilateral type I papil-
lary renal cancers. No other extrarenal manifestations
have been reported in this syndrome. Sporadic type I
papillary renal tumors have a better prognosis than
other cell types, so it is not surprising that the tumors
associated with HPRC tend to be slow growing and
rarely cause death [39]. Because of the favorable
prognosis of HPRC, the patient may not come to
medical attention and the disease often is not diag-
nosed until the patient is in their fifth decade. In
VHL, the patient is often diagnosed in their teens
and twenties.
The gene responsible for HPRC has been located
at 7q 31.3 and is known as the c-MET proto-onco-
gene [40]. This gene was first described in 1984 but
was only recently linked to renal cancer [41]. Unlike
VHL where it is thought that a mutation leads to
lower levels of the VHL protein, c-MET seems to be
overexpressed in type 1 papillary tumors. The gene
codes for a transmembrane tyrosine kinase, which
acts as a receptor for hepatocyte growth factor. The
mutations associated with HPRC are found on the
extracellular portion of the transmembrane protein
where hepatocyte growth factor interacts with the
receptor. The mechanism by which the mutated
protein causes tumor formation, however, is still
unknown. Interestingly, alterations in the hepatocyte
growth factor receptor have also been found in VHL-
related tumors [42]. Moreover, there is some evidence
that sporadic papillary renal tumors found in the
general population that have c-MET alterations are
more biologically aggressive [42]
Unlike clear cell carcinomas of VHL that are
highly vascular on contrast-enhanced CT, the lesions
of HPRC tend to be hypovascular (Fig. 6). Indeed, if
density measurements are not obtained carefully,
some lesions may be mistaken for cysts [41,43].
The change in enhancement before and after intra-
venous contrast media can be as little as 10 to 15 HU.
This places a premium on obtaining scans of high
quality with the same technique (kilovolt [peak],
milliamp, slice thickness, field of view, and so forth)
both before and after contrast media administration.
The CT protocol used in these cases is the same one
used for VHL patients, namely precontrast, arterial,
and venous phase postcontrast helical CT. Enhance-
ment on MR imaging after gadolinium chelate ad-
ministration is often very modest (15% to 20% over
baseline) [30,43]. Renal sonography can be mislead-
ing because the lesions are often isoechoic when they
are less than 3 cm in diameter and sonography should
not be used to monitor patients with HPRC [43].
Hereditary papillary renal cancer can be suspected
in a patient with two or more poorly enhancing renal
masses. Renal cystic disease is not usually a feature of
the disease but incidental cysts can occur in HPRC. If
the patient has a family history of renal cancer and
particularly if the cell type is papillary type I, the
presumptive diagnosis of HPRCcan be made. This can
be confirmed with genetic testing of peripheral blood.
Fig. 4. Intraoperative ultrasound of a mixed solid and cystic
lesion within the kidney. Note that the mass is below the
surface of the kidney (arrows) and is not visible to the
surgeon. Intraoperative ultrasound assists the surgeon by
demonstrating the parenchyma deep to the surface.
Fig. 5. Patient with von Hippel-Lindau disease successfully
treated with laparoscopically assisted radiofrequency abla-
tion. Note a solid lesion (arrow) on the pretreatment study
(A) has become nonenhancing and smaller 6 months after
treatment with RF ablation (B). Cystic disease is also present
in the head of the pancreas.
Treatment of HPRC renal tumors is similar to
VHL. It is generally believed that surgery can be
delayed until one of the tumors reaches 3 cm in
diameter and that renal-preserving surgery should be
attempted whenever feasible. If the tumor is found at
a diameter greater than 3 cm every attempt should be
made to perform a nephron-sparing procedure. If that
is not possible, however, a nephrectomy may be
required. Alternatively, minimally invasive radiofre-
quency ablation or cryoablation may be suitable in
some patients. In general, the prognosis for HPRC is
considered excellent and many patients live normal
lives with this condition. The radiologist, however,
should be alert to the possibility of HPRC when
multiple or bilateral low-density solid renal tumors
are seen.
Hereditary leiomyoma renal cell carcinoma
Hereditary leiomyoma renal cell carcinoma
(HLRCC) is an autosomal-dominant genodermatosis
that causes cutaneous leiomyomas, uterine leiomyo-
mas, and type II papillary renal cancers. The syn-
drome, originally described in Finland among families
with hereditary uterine leiomyoma, has now been
seen throughout Europe and North America. The
association of cutaneous and uterine leiomyomas is
known as Reeds syndrome but the association with
renal tumors is only recent [44]. The hallmarks of
HLRCC are (1) cutaneous leiomyomas over the trunk
and extremities and more rarely the face; (2) uterine
fibroids at an early age (< 30 years); and (3) type II
papillary renal tumors.
The gene for HLRCC is found on the first
chromosome (1q42.3) and is known as fumarate
hydratase. Interesting, this enzyme is a critical step
in the Krebs tricarboxylic acid cycle but its role in
causing renal tumors is not understood. Fumarate
hydratase likely acts as a tumor suppressor because
fumarate hydratase enzyme activity is low or absent
in tumors found in HLRCC [45].
Type II papillary renal cancers are found in about
17% of individuals with HLRCC and can be clini-
cally aggressive (Fig. 7). Metastases are seen in over
half of cases even with relatively small primary
tumors. HLRCC renal tumors differ from the other
hereditary renal cancer syndromes in several impor-
tant ways. Histologically, they appear to be type II
papillary tumors except for the occasional collecting
duct renal cancer. The renal tumors in HLRCC are
usually solitary and unilateral as opposed to the other
syndromes, where the tumors are usually multiple
and bilateral. The tumors are also substantially more
aggressive with Furman nuclear grades of 3 or 4 in all
cases reported and a tendency to metastasize even
when small (see Fig. 7). In contrast, the tumors
associated with VHL and HPRC are typically only
Furman nuclear grade 1 or 2 and these tumors rarely
metastasize when less than 3 cm in diameter. It is
particularly important to differentiate HLRCC from
HPRC. Whereas one might follow a patient with
HPRC with watchful waiting, treatment is more
Fig. 6. (A) Precontrast CT; (B) postcontrast CT. Patient with
hereditary papillary renal cancer demonstrates a poorly
enhancing mass in the right kidney. This lesion increased in
CT attenuation by only 12 HU after intravenous contrast.
Minimally enhancing solid tumors are typical of the tumors
found in HPRC.
urgent in patients with HLRCC. Tumors should be
removed when they are first seen.
Uterine fibroids occur in over 90% of women with
HLRCC. Most of these women also had skin leio-
myomas. Almost half the women with HLRCC
require a hysterectomy by the age of 30 (see Fig. 7).
In addition to screening for renal cancers patients
should be screened for uterine leiomyomas and
leiomyosarcomas. It is thought that this entity has a
higher frequency of transformation to malignant
leiomyosarcoma within the uterus, although criteria
for distinguishing these transformations by imaging
are lacking [45]. Although the cutaneous leiomyomas
do not degenerate into malignancies in general, a few
cases of cutaneous leiomyosarcomas have been
reported [45]. The cutaneous manifestations become
more prominent with age; they are hardly noticeable
when the patients are young but can become a cos-
metic issue when the patient reaches 30 to 40 years
of age.
CT is used to screen for HLRCC renal cancers and
assess the status of the uterus. Interestingly, although
the tumors tend to be hypovascular like type 1
papillary tumor, they are much more lethal. Careful
screening for metastatic disease should be performed.
MR imaging and ultrasound are suitable substitutes
when contrast-enhanced CT cannot be performed.
MR imaging of the uterus is particularly helpful in
detecting and characterizing uterine leiomyomas.
Birt-Hogg-Dube syndrome
Birt-Hogg-Dube syndrome (BHD), an autosomal-
dominant disorder, was originally described as a
dermatologic disorder characterized by fibrofollicu-
lomas (growths in the hair follicles) of the face and
trunk [46]. Later it became clear that there were other
markers for the disease including pulmonary cysts
and renal tumors [47,48]. The pulmonary cysts vary
in severity and size from one or two small, scattered
cysts to severe cystic disease complicated by sponta-
neous pneumothoraces, which may be refractory to
conventional pleurodesis. Between 15% and 30% of
patients with BHD develop renal cancers. The renal
tumors seen in BHD are commonly, but not always,
chromophobe carcinomas or oncocytomas. Both clear
cell and papillary tumors have also been seen in BHD
[34]. Approximately 34% of the tumors are charac-
terized as chromophobe carcinomas and about 50%
are hybrid chromophobe-oncocytomas. The remain-
der are oncocytomas (5%); clear cell carcinoma (9%);
and papillary renal cancer (2%) [34]. A higher rate of
colonic polyps have been observed in some families
but the risk for colon cancer has not been clearly
defined [49,50].
The gene for BHD is located at 17p11.2 and codes
for a protein named folliculin [48,49]. Little is known
of the mechanism of tumor formation or the function
of folliculin. It is thought that this gene acts as a
tumor suppressor and acts as a structural protein in
Fig. 7. Hereditary leiomyoma renal cell carcinoma. (A) A
small mass (3 cm) is present in the middle portion of the left
kidney. It is poorly enhancing typical of papillary renal
cancer; however, in addition there is a metastatic lympha-
denopathy (arrow) adjacent to the aorta. This proved to be a
papillary type II renal cancer. The renal lesion was not
visible on ultrasound. (B) Abdominal CT in another patient
(aged 32) with HLRCC demonstrates multiple enhancing
leiomyomas within the uterus.
the lung where it may form a component of the
cytoskeletal network. This might explain the tend-
ency of BHD patients to develop lungs cysts. The
Hornstein-Knickenberg syndrome overlaps BHD and
is now considered to be part of BHD [51]. BHD
differs from other forms of hereditary renal cancer in
that it produces a variety of cell types of renal cancer,
not just one but chromophobe cancers and their
variants predominate. The chromophobe tumors and
oncocytomas also arise from the distal renal tubules
in contrast to VHL and HPRC-related tumors that
arise from the proximal tubules [48].
The imaging of BHD should always include scans
of the lungs and abdomen (Fig. 8). The pulmonary
cysts are generally found in the lower lobes and vary
in size and number from a few to multiple. Pneumo-
thoraces may be seen despite the absence of symp-
toms. Although severe cystic disease is present in
some individuals the patients do not usually become
oxygen-dependent. This differs from the cystic lung
disease found in lymphangioleiomyomatosis asso-
ciated with tuberous sclerosis (TS, see later). The
chromophobe or mixed cell types typically demon-
strate moderate uniform enhancement on CT, which
is different in appearance from VHL-associated
tumors, which typically have cystic components.
Birt-Hogg-Dube syndrome is managed in a man-
ner similar to VHL. Tumors are generally observed
until they reach 2 to 3 cm diameter, whereupon
nephron-sparing surgery is performed. Chromophobe
carcinomas tend to be highly enhancing and are
relatively homogeneous in appearance. Radiofre-
quency ablation or cryotherapy also can be consid-
ered, although little outcome data are yet available.
Familial renal oncocytoma
Familial renal oncocytoma (FRO) is an incom-
pletely characterized condition in which affected
individuals develop renal oncocytomas [8]. The term
familial is used instead of hereditary to denote
that a clear hereditary pattern has not yet been
established. Five families with a hereditary predispo-
sition to renal oncocytomas were first described
by Weirich et al in 1998 [52]. Some families had
Fig. 8. Birt-Hogg-Dube syndrome. (A) Contrast-enhanced CT demonstrates an enhancing mass in the right kidney typical of a
chromophobe carcinoma. (B) Additional smaller lesion is present in the lower pole. (C) Pulmonary CT demonstrates multiple
cysts and a loculated pneumothorax (arrow). This patient had experienced multiple pneumothoraces as a consequence of cystic
lung disease.
extensive bilateral disease, and compromised renal
function [11]. Other families had mild manifestations
of FRO. There may be some overlap with BHD
because several families initially considered to have
FRO proved to have features of BHD. Renal dys-
function without extensive neoplastic disease was
also noted in some family members. The prevalence
of this entity is unknown and no putative genetic
locus has yet been identified.
The diagnosis is based on the identification of
multiple oncocytomas in one or more family mem-
bers. By imaging, the lesions are indistinguishable
from malignant renal cancers and must be treated as if
they were renal cancers (Fig. 9) [53]. When onco-
cytomas are extensive and confluent the term renal
oncocytosis can be applied [11]. Because renal
function is often compromised these patients are
often scanned with MR imaging using gadolinium-
based contrast agents. Lifelong monitoring with
imaging studies is recommended, although compli-
ance is lower because the perceived risk by the
patient is reduced.
Medullary carcinoma
Medullary carcinoma of the kidney is a rare
aggressive neoplasm that develops in young, black
patients (age range, 11 to 39 years) with sickle cell
trait [54]. This has led some observers to comment
that the renal tumors may be a secondary complica-
tion of sickle cell trait [55]. This seems doubtful
because the sickle cell trait produces only mild
symptoms and the youth of the patients (median
age about 20 years) makes it unlikely to be the result
of a chronic process. The rate of renal tumor develop-
ment even among people with sickle cell trait is low.
Approximately 1 in 12 blacks have Hb AS (sickle cell
trait) and relatively few reports of medullary carci-
noma of the kidney have been published [56]. The
risk of developing medullary carcinoma of the kidney
even in the presence of sickle cell trait is negligible.
The sickle cell gene is located at 11p15.
Unfortunately, the tumors at presentation tend to
be large and are often metastatic. The tumor is
generally advanced by the time it is discovered;
median survival from the time of diagnosis is only
15 weeks [57]. Surgery seems to be useful only in
providing palliation.
The tumors are generally large, central, and hetero-
geneous in character. There is often evidence of ade-
nopathy or pulmonary metastases. These tumors
should be evaluated with MR imaging or CT before
surgery to provide accurate clinical staging (nodal
and inferior vena caval involvement). Systemic thera-
pies are recommended but have failed significantly to
modify the course of the illness.
Other syndromes
Tuberous sclerosis
Tuberous sclerosis is a genetic disease character-
ized by hamartomas in the skin, brain, and viscera.
Although not technically considered a cancer syn-
drome, TS is associated with an increased risk of
renal malignancy. TS has prevalence in the popula-
tion of approximately 1:10,000. The most common
manifestations of TS in the kidneys are cysts and
angiomyolipomas. Approximately a third of angio-
myolipomas may not contain fat visible by CT and
are difficult to differentiate from cancer. Most often
the mass represents a nonfatty angiomyolipoma.
Approximately 1% to 2% of patients with TS develop
renal cancers, which is substantially higher than the
expected rate of renal cancer in the general popula-
tion [58,59].
There is a complex relationship between renal
cancer and TS. Renal cancers are found with in-
creased frequency in patients with TS compared with
the general population and have been identified with
mutations in both TSC1 and TSC2, the two gene loci
associated with TS [59,60]. Occasionally, renal can-
cers are even the presenting sign of TS [61]. Multi-
focal renal cancer has been found in siblings from a
Fig. 9. Hereditary renal oncocytoma. Bilateral renal oncocy-
tomas are present in this patient. Note that the lesions are
homogeneously enhancing. Stellate central scars, seen com-
monly in sporadic oncocytomas, are unusual in this condition.
single family with TSC1 [62]. Features indicating an
association with renal cancer include a striking
female predominance (81% female versus 70% male
predominance for sporadic renal cancers); median
age of only 28 years (versus sixth and seventh
decades for sporadic renal cancers); multifocality;
and bilaterality (43%) [63,64]. Supportive evidence
comes from the animal model of TS, the Eker rat,
which has an insertional mutation in the rat TSC2
gene. The Eker rat develops tumors (adenomas and
carcinomas) and cysts in the kidney [65]. Avariety of
cell types of renal cancers have been reported in
humans with TS including clear cell (most common)
papillary and chromophobe carcinomas [66,67].
Oncocytomas have also been reported with increased
frequency in TS [68]. Some doubt has been raised
concerning the actual origin of some renal tumors in
TS because some lesions may actually be malignant
epithelioid angiomyolipomas, which can mimic renal
cancers [69].
Translocation of chromosome 3
A number of families have been reported in which
part of the short arm of chromosome 3 has been
translocated to another chromosome [9,17]. These
balanced translocations predispose the patient to the
development of clear cell carcinomas of the kidney.
Because VHL is also located on chromosome 3 it was
originally assumed that this was a subset of VHL;
however, patients with chromosome 3 translocation
do not have other stigmata of VHL and the VHL
portion of the short arm of chromosome 3 is often
intact [70,71]. Translocation of the chromosome 3
can result in a clear-cell predominant form of heredi-
tary renal cancer. Unlike the other syndromes, which
require a careful analysis of the genes for mutations,
this abnormality can be detected on a karyotype of
peripheral white blood cells.
Familial renal cancer
Not all families with tendencies to develop renal
cancers are explained by the syndromes described
previously. As a result, the term familial renal
cancer is used to characterize patients with apparent
genetic predisposition to renal cancer in whom the
exact gene involved has not yet been determined.
Fortunately, as more is learned about the origins of
hereditary renal cancer this category contains fewer
patients and more are successfully characterized by
specific diagnoses.
Summary
Over the past 5 years there have been dramatic
developments in the extent of knowledge of heredi-
tary renal cancers. In addition to VHL, which is
associated with clear cell carcinoma, one can now
list HPRC (associated with type I papillary renal
cancer) and HLRCC (associated with type II papillary
renal cancer). BHD and FRO are associated with
chromophobe carcinoma and oncocytomas, although
other histologic tumor types have been found in
BHD. Medullary carcinoma of the kidney is asso-
ciated with sickle cell trait. Although the genes
associated with these tumors have been discovered,
the exact mechanisms by which they cause renal
cancer remain to be elucidated. It is quite likely that
other genes also are involved in this process. Using
VHL as an example, research is now underway on
targeting mutant pVHL or excess HIF for diagnostic
and therapeutic purposes. Understanding the mecha-
nisms leading to cancer may open new targets of
opportunity for drug development. This improved
knowledge of the biogenetic pathways used to form
tumors will impact the development of new thera-
peutic techniques for treating renal cancers in heredi-
tary and nonhereditary forms of the disease.
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Surgical management of renal tumors
Rizk El-Galley, MB Bch, FRCS
Department of Surgery, Division of Urology, University of Alabama at Birmingham, 1530 3rd Avenue South, MEB 602,
Renal cell carcinoma is a relatively rare tumor,
accounting for approximately 3% of malignancies in
adults, but is the most common tumor of the kidney
and the third most common tumor seen by urologists
[1]. The classic symptom triad of pain, hematuria,
and flank pain is certainly a reliable clinical symptom
complex. More recently, however, most renal cell
carcinomas are diagnosed at earlier stages and are
frequently found incidentally at radiologic investiga-
tion done for other reasons [2].
Renal cell carcinoma is refractory to most tradi-
tional oncologic treatments, including chemotherapy,
radiation therapy, and hormonal therapy [35]. Radi-
cal nephrectomy, removing all the contents of Ge-
rotas fascia, is considered the standard treatment for
localized tumors. More recent data indicate, however,
that in carefully selected patients partial nephrectomy
may be an option [68]. The role of radical nephrec-
tomy in patients with metastatic disease is contro-
versial and is not indicated unless the patient has
intractable bleeding or pain, or it is necessary to debulk
the tumor for immunotherapy or other systemic thera-
pies. Local extension into the renal vein or inferior
vena cava (IVC) is not considered a contraindication to
radical nephrectomy. Tumor extension beyond Gero-
tas fascia involving other organs is associated with
poor prognosis, however, and nephrectomy should be
considered only for palliation or as part of an adjuvant
therapy protocol [912].
Because of recent advances in sophisticated ra-
diologic studies, the surgeon can now make an
accurate preoperative assessment of the nature and
extent of kidney tumors. The diagnosis of renal cell
carcinoma is generally made with CT, showing a
solid mass in the parenchyma of the kidney. Fewer
than 5% of all renal cell carcinomas have a cystic
appearance with septations, irregular borders, dystro-
phic calcification, or other features that distinguish it
from a simple renal cyst.
The differential diagnosis of solid kidney masses
includes oncocytoma (granular oncocytes on histo-
logic analysis, with a central scar in the tumor);
angiomyolipoma (contains fat, seen on CT scans);
xanthogranulomatous pyelonephritis (usually in pa-
tients with diabetes, with a concurrent stone in a
poorly functioning kidney); fibromas; or metastasis.
Despite the diagnostic clues seen at radiologic inves-
tigation, the histologic nature of these masses cannot
be confirmed without tissue biopsy, which is gener-
ally avoided because of the risk for seeding malignant
cells through the needle track or the possibility of
obtaining benign tissue approximating a malignant
area. Accordingly, in most of these patients radical
nephrectomy is required before the kidney lesion is
finally diagnosed pathologically.
CT and MR imaging are the imaging studies most
commonly used to stage renal tumors. Abdominal CT
is particularly useful to show local extension of tumor
and the presence of enlarged para-aortic lymph nodes.
MR imaging is superior to CT for determining the
superior extent of a vena caval thrombus; however,
the new generation of CT scanners with rapid image
acquisition are as accurate as MR imaging in vena
caval imaging [13,14]. These new imaging studies
have replaced, to large extent, venocavography and
arteriography, which are more invasive. Chest radiog-
raphy or chest CT is routinely done to rule out
pulmonary metastasis; bone scanning is required only
in the presence of a large tumor or if clinical evalua-
tion suggests metastasis to bone.
When evaluating renal tumors, the urologist is
looking for certain information to help in constructing
doi:10.1016/S0033-8389(03)00077-0
E-mail address: rizk.el-galley@ccc.uab.edu
Radiol Clin N Am 41 (2003) 10531065
a management plan. Here are some of the points that
contribute in the surgical decision-making.
Is it a kidney a tumor or a pseudotumor?
Pseudotumors in the kidney are rare; however, this
diagnosis should be taken into consideration. A
hypertrophied column of Bertin, inflammatory renal
mass, or perinephric inflammation extending to the
kidney may be confused with a renal tumor. A CT
scan is usually very helpful in delineating the nature
of these tumors. In some cases, when the nature of the
mass in undetermined, a repeat CT a few weeks later
shows a significant change in an inflammatory mass,
whereas a tumor change is less remarkable. A hyper-
trophied column of Bertin has been a diagnostic
problem on intravenous pyelogram and a dimercap-
tosuccinic acid (DMSA) nuclear scan was required to
establish the diagnosis; a column of Bertin is homog-
enous with the rest of the kidney tissue, whereas a
tumor shows different isotope uptake. Most of these
swellings, however, can be differentiated with a CT
scan that obviates the need for a nuclear scan [15,16].
Is it a cystic tumor?
Cystic renal masses range from a simple cyst to
cystic renal carcinoma. Characterization of cystic
renal masses relies mainly on the Bosniak classifica-
tion, which consists of four categories [1719]:
benign simple cysts (category I); minimally compli-
cated cysts (category II); indeterminate cystic renal
masses that include cystic renal tumors (multilocu-
lated or not) and complex cysts (category III); and
cystic renal cell carcinomas (category IV). Usually,
category I cysts are not indication for surgery unless
they are symptomatic, category II are most likely
benign and can be watched, category III are more
likely to be malignant, and category IV are highly
suspicious for being malignant [20,21].
Is it a solid renal tumor?
In general, solid renal tumors should be consid-
ered malignant until proved otherwise, with the
exception of a tumor that contains fat on the CT
scanning (angiomyolipoma) or tumors that do not
enhance on a CT and do not grow on follow-up CTs.
Oncocytoma is another tumor that is difficult to
differentiate from malignant tumors radiologically
and is usually diagnosed after excision [22].
Surgical planning is usually dependent on radio-
logic information. The extent of the tumor and its
location in the kidney, proximity to the renal collecting
system and renal vessels, and presence of fat planes
between the tumor and other structures (eg, liver,
colon, and posterior abdominal wall muscles) are all
important information that help the surgeon to assess
the local invasiveness of the tumor. Similarly, tumor
extension into the renal vein or IVC and the level of
this extension are essential information in surgical
decision-making. Tumors that extend beyond the distal
two thirds of the renal vein are not suitable for
laparoscopic surgery. The level of extension in the
IVC should be assessed accurately before surgery.
Tumors that extend above the hepatic veins require
full mobilization of the liver to control the IVC above
the hepatic veins. It also requires the Pringle maneuver
(clamping the porta hepatis), clamping the renal veins
and the lumbar veins to reduce blood loss during tumor
extraction from the IVC. Tumors that extend into the
right atrium require the involvement of a cardiotho-
racic surgeon and cardiopulmonary bypass to extract
the tumor from the IVC and atrium. The presence of
intra-abdominal metastasis, the function of the contra-
lateral kidney, and the appearance of the adrenal glands
are valuable information for surgical decision making.
Surgical anatomy of the kidneys
The kidneys are paired, reddish brown, solid
organs situated on each side of the midline in the
retroperitoneal space. Their weight depends on body
size, averaging 150 and 135 g each in the adult man
and woman, respectively. Kidneys in mature adults
vary in length from 11 to 14 cm, in width from 5 to
7 cm, and in thickness from 2.5 to 3 cm. Because of
the effect of the hepatic mass, the right kidney is
shorter and broader and lays 1 to 2 cm lower than the
left kidney.
Each kidney is surrounded by a layer of fat, covered
by the Gerotas fascia (Fig. 1). Gerotas fascia is
completely fused above and lateral to the kidney;
medially and inferiorly fusion is incomplete. This
incomplete fusion is of clinical importance in deter-
mining the possible routes of spread of bleeding or
infection around the kidneys. Both layers of Gerotas
fascia probably continue across the midline, with the
posterior layer crossing behind the great vessels and
the anterior layer extending in front of the great
vessels. The parietal peritoneumfuses with the anterior
layer of Gerotas fascia to form the white line of Toldt
laterally. During surgical approaches to the kidneys,
incision along this line enables the surgeon to reflect
R. El-Galley / Radiol Clin N Am 41 (2003) 10531065 1054
the peritoneum with the mesocolon through a relative-
ly bloodless plane and gives access to the renal hilum.
The upper pole of the left kidney lies at the level
of the twelfth thoracic vertebral body and the lower
pole at the level of the third lumbar vertebra (Fig. 2).
The right kidney usually extends from the top of the
first lumbar vertebra to the bottom of the third lumbar
vertebra. Because of the free mobility of the kidneys,
these relationships change with both body position
and respiration.
The right adrenal gland covers the uppermost part
of the anteromedial surface of the right kidney. The
anterior relationships of the right kidney include
the liver, which overlies the upper two thirds of the
anterior surface, and the hepatic flexure of the colon,
which overlies the lower third. The right renal hilum
is overlaid by the second part of the duodenum. The
anterior surface of the kidney beneath the liver is the
only area covered by peritoneum. The anteromedial
surface of the left kidney is also covered by the left
adrenal gland in its uppermost part. The spleen, body
of the pancreas, stomach, and splenic flexure of the
colon are all anterior to the left kidney. The area of
the kidney beneath the small intestine, the spleen, and
the stomach is covered by peritoneum. Both kidneys
share relatively symmetric relations to the posterior
abdominal wall. The upper third or upper pole of each
kidney lies on the diaphragm, behind which is the
pleural reflection. An operative approach to this area
with a high incision above the eleventh or tenth rib
risks entering the pleural space. The upper border of
the left kidney usually extends to the upper border of
the eleventh rib, and the upper pole of the right
kidney, which is lower, is usually at the level of the
eleventh intercostal space. The lower two thirds of the
posterior surface of both kidneys lies on three
muscles, which from medial to lateral are the psoas
major, quadratus lumborum, and the aponeurosis of
the transversus abdominis muscles. The renal vessels
and pelvis lie against the contour of the psoas muscle,
which tilts the lower pole of each kidney away from
the midline. Alterations in this alignment may be seen
with space-occupying lesions and should prompt
careful assessment.
The renal parenchyma is divided into an internal
darker medulla and an external lighter-hued cortex
(Fig. 3). The medulla is composed of 8 to 18 conical
structures called the renal pyramids, which are
made of ascending and descending loops of Henle
and collecting ducts. The round tip of each pyramid is
known as the renal papilla. These papillae cannot be
seen during surgical dissections because each papillary
projection is encompassed by a smooth muscular
sleeve called a minor calyx. These minor calyces
Fig. 1. Gerotas fascia. (From El-Galley RES, Keane TE. Kidneys, ureters, and bladders. In: Wood WC, Skandalakis JE, editors.
Anatomic basis of tumor surgery. St. Louis: Quality Medical Publishing; 1999; with permission.)
coalesce to form two or three major calyces, which in
turn join to form the renal pelvis. The renal pelvis
extends through the renal hilum behind the renal
vessels and continues as the ureter. Anatomic varia-
tions in the renal pelvis are not uncommon. The renal
pelvis, which is usually partially extrarenal, may lie
completely outside or within the kidney. Occasionally
the renal pelvis may be duplicated, with duplication of
the renal units. Anatomic variations of the renal pelvis
tend to occur bilaterally, which should be considered
when evaluating urographic studies to differentiate
pathologic conditions from normal variations.
The renal cortex lies between the bases of the
pyramids and the renal capsule. The tongues of cortical
tissue that extend between the renal pyramids are
called the columns of Bertin and, when enlarged,
can closely resemble a renal mass. The outer border of
the renal cortex should be smooth. Indentations on the
cortical surface might represent persistent fetal lobu-
lations, previous scarring, and infection or space-
occupying lesion.
Blood supply
Each kidney is classically supplied by a renal
artery and a larger renal vein, arising from the aorta
and the IVC, respectively, at the level of the second
lumbar vertebra below the takeoff of the superior
mesenteric artery (Fig. 4). These vessels enter the
renal hilum medially, with the vein anterior to the
artery and both anterior to the renal pelvis. Although
the right kidney is lower than the left kidney, the right
renal artery arises from the aorta at a higher level and
takes a longer course than the left renal artery. It
travels downward behind the IVC to reach the right
kidney, whereas the left renal artery passes slightly
upward to reach the left kidney. Because of the
posterior position of the kidneys, both renal arteries
course slightly posterior. Two small but important
branches arise from the main renal artery before its
termination in the hilum: the inferior adrenal artery and
the artery that supplies the renal pelvis and upper
ureter. Ligation of this branch may result in ischemia
Fig. 2. Location of kidneys. (From El-Galley RES, Keane TE. Kidneys, ureters, and bladders. In: Wood WC, Skandalakis JE,
editors. Anatomic basis of tumor surgery. St. Louis: Quality Medical Publishing; 1999; with permission.)
to the area of the upper ureter with stricture formation.
The main renal artery divides into five segmental
arteries at the renal hilum. Each segmental artery is
an end artery; occlusion leads to ischemia and infarc-
tion of the corresponding renal segment. The first
branch is the posterior artery, which arises just before
the renal hilum and passes posterior to the renal pelvis
to supply a large posterior segment of the kidney. The
main renal artery then terminates into four anterior
segmental arteries at the renal hilum: (1) the apical,
(2) upper, (3) middle, and (4) lower anterior segmental
arteries (Fig. 5). Both the apical and inferior arteries
supply the anterior and posterior surfaces of the upper
and lower poles of the kidneys, respectively. The upper
and middle arteries supply two corresponding seg-
ments on the anterior surface of the kidney. Renal
vascular segments are also identified.
The segmental arteries course though the renal
sinus and branch into the lobar arteries, which are
usually distributed one for each pyramid. Each lobar
artery divides into two or three interlobar arteries that
pass between the renal pyramids to the corticomedul-
lary junction, where they become the arcuate artery.
The arcuate arteries, as their name implies, arch over
the bases of the pyramids and give rise to a series of
interlobular arteries, which in turn take a straight
course to the renal cortex, with some terminal small
branches anastomosing with the capsular arteries. This
Fig. 4. Blood supply to the kidney (anterior surface of right kidney). (From El-Galley RES, Keane TE. Kidneys, ureters, and
bladders. In: Wood WC, Skandalakis JE, editors. Anatomic basis of tumor surgery. St. Louis: Quality Medical Publishing; 1999;
with permission.)
Fig. 3. Anatomy of renal parenchyma. (From El-Galley
RES, Keane TE. Kidneys, ureters, and bladders. In: Wood
WC, Skandalakis JE, editors. Anatomic basis of tumor
surgery. St. Louis: Quality Medical Publishing; 1999;
with permission.)
anastomosis can enlarge to supply a significant amount
of blood to the superficial cortical glomeruli, particu-
larly in cases of gradual narrowing of the renal arteries.
The renal cortex is drained by the interlobular veins,
which, unlike the renal arteries, anastomose freely with
the arcuate veins at the base of the medullary pyramids
and with the capsular and perirenal veins on the surface
of the kidney. The arcuate veins drain through the
interlobar veins to the lobar veins, which join to form
the renal vein. The right renal vein, 2 to 4 cm long,
joins the lateral aspect of the IVC, usually without
receiving any tributaries. The left renal vein, 6 to 10 cm
long, crosses anterior to the aorta and ends in the left
aspect of the IVC. It receives three tributaries lateral to
the aorta: (1) the left adrenal vein superiorly, (2) left
gonadal vein inferiorly, and (3) a lumbar vein poste-
riorly. At the renal hilum the renal vein usually lies in
front of the renal artery. Passing more medially,
however, the renal artery may be a centimeter higher
or lower than the vein.
Lymphatic drainage
Lymphatic vessels within the renal parenchyma
consist of cortical and medullary plexuses that follow
the renal vessels to the renal sinus and form several
large lymphatic trunks. The renal sinus is the site of
numerous communications between lymphatic ves-
sels from the perirenal tissues, renal pelvis, and upper
ureter. Initial, lymphatic drainage runs to the nodes
present at the renal hilum lying close to the renal
vein. These nodes form the first station for lymphatic
spread of renal cancer. On the left side, lymphatic
trunks from the renal hilum drain to the para-aortic
lymph nodes from the level of the inferior mesenteric
artery to the diaphragm. Lymphatic vessels from the
right kidney drain into the lateral paracaval and
interaortocaval nodes from the level of the common
iliac vessels to the diaphragm. Lymphatic vessels
from both sides may extend above the diaphragm to
the retrocrural nodes or directly into the thoracic duct.
Surgical applications
The kidneys can be approached through various
incisions: lumbar, anterior transperitoneal, thoraco-
abdominal, and posterior lumbar. Factors that should
be taken into consideration before selecting an inci-
sion include type of operation and pathologic condi-
tion, body habitus, and pulmonary or spinal
deformities. Small uncomplicated tumors can be
approached through an extraperitoneal flank incision.
This approach has the advantages of being extraperi-
toneal, with a shorter period of ileus, and in obese
patients most of the panniculus falls away from the
kidney. Exposure of the renal pedicle with lateral
lumbar approaches is not as good as an anterior
approach, however, and runs the risk of entering the
pleural cavity, particularly if a supracostal incision is
performed. This incision can be performed above the
twelfth or eleventh rib, either extrapleural or intra-
Fig. 5. Vascular segments (left kidney). (From El-Galley RES, Keane TE. Kidneys, ureters, and bladders. In: Wood WC,
Skandalakis JE, editors. Anatomic basis of tumor surgery. St. Louis: Quality Medical Publishing; 1999; with permission.)
pleural, to expose the suprarenal gland or the upper
pole of the kidney, and can also be extended down-
ward to expose the ureter.
For good exposure of the renal vessels, particu-
larly for operations for advanced tumors, an ante-
rior transperitoneal approach is preferred. It can be
performed through an anterior subcostal, midline,
or paramedian incision. The midline incision is
faster to perform and to close, but the incidence
of incisional hernia is higher than with paramedian
incisions. Posterior lumbar incisions are easy to
perform and are easier on the patient, but the
exposure is limited, particularly with respect to
renal vessels. Good access is provided to the renal
pelvis and upper third of the ureter for stone
surgery, but this approach is not recommended
for malignancies.
Radical nephrectomy
The eleventh or twelfth rib supracostal incision,
with attempt to remain extrapleural, is recommended
for most cases. It provides good exposure of the
kidney, renal pedicle, and adjacent organs. Thora-
coabdominal incision is preferable in patients with
large upper pole tumors or tumors that extend into the
IVC, although median sternotomy is an option for
high caval thrombi. Unilateral anterior extraperitoneal
incision provides adequate exposure in noncompli-
cated cases. Bilateral tumors can be approached with
a midline or Chevron incision; however, such lesions
are best approached one side at a time.
On the right side, once the peritoneum is entered,
the intra-abdominal contents, mainly the liver, are
inspected for unrecognized metastasis, and the tumor
is examined carefully for resectability. The dia-
phragm is retracted superiorly with a self-retaining
retractor, and countertraction is applied to the supe-
rior border of the rib below after releasing the
costochondral ligament. The liver is kept out of the
way by gentle retraction to prevent hepatic injury.
During extensive IVC mobilization care must be
taken not to injure the short caudate veins.
Attention should be given to the renal pedicle,
which can be approached ventrally by retracting the
ascending colon and dividing the lateral paracolic
peritoneum (Fig. 6). The hepatic flexure and duode-
num are mobilized medially to expose the renal
pedicle and the renal veins lying in front of the artery.
As an alternative, with the dorsal approach to the
renal pedicle the renal artery is readily accessible for
ligation and division. This maneuver significantly
reduces potential blood loss. It can be performed by
dissecting the kidney and surrounding tissues free
Fig. 6. Approach to the renal pedicle. (From El-Galley RES, Keane TE. Kidneys, ureters, and bladders. In: Wood WC,
Skandalakis JE, editors. Anatomic basis of tumor surgery. St. Louis: Quality Medical Publishing; 1999; with permission.)
from the posterior abdominal wall and rotating it
medially, after which the renal artery can be identi-
fied, ligated, and divided.
The ureter, gonadal vessels, and periureteral fat
are dissected free of the posterior peritoneum and
divided in two or three separate bundles. The dissec-
tion is then carried superiorly along the IVC on its
anterior surface, where there are few, if any, signifi-
cant branches.
Superior to the renal vessels the peritoneum fans
out laterally, and the dissection is performed to the
lateral border of the peritoneum. In most larger tumors
and some smaller tumors, the peritoneum cannot be
dissected free of Gerotas fascia, and the surgeon is
forced to remove a window of peritoneum with the
specimen. Care should be taken to avert injury to the
bowel, especially the C portion of the duodenum.
The superior portion of the specimen, including the
adrenal gland, should be dissected free of the retro-
peritoneum and liver. Because there may be branches
of the phrenic and other vessels at this point, the author
generally uses a series of large hemoclips, dividing the
tissue below the clips to enhance hemostasis.
On the left side, the descending colon is retracted
medially, and the lateral reflection of the peritoneum
is incised (Fig. 7). The mesentery is dissected bluntly
from the anterior surface of Gerotas fascia. Care
should be taken to prevent injury to the pancreas,
which is mobilized medially. If the tumor extends
into the colonic mesentery, this part of the mesentery
can be resected with the specimen without great risk
for colonic ischemia as long as the marginal artery is
not disrupted. The kidney and surrounding tissues are
dissected free from the posterior abdominal wall and
rotated medially, and the renal artery is identified,
ligated, and divided. In bulky tumors the superior
mesenteric artery might be displaced laterally; great
care should be taken to distinguish the superior
mesenteric artery from the renal artery on either side.
The ureter, gonadal vessels, and periureteral fat are
dissected free of the posterior peritoneum and divided
in two or three separate bundles. The dissection is then
carried superiorly along the aorta on its anterior
surface, where there are few significant branches.
The splenorenal ligament is identified, ligated, and
divided to avert splenic injury during mobilization of
the kidney. The superior portion of the specimen
should be dissected free of the retroperitoneum.
The specimen should be free at this point except for
the venous structures. The left adrenal vein drains into
Fig. 7. Kidney and surrounding tissues dissected free from the posterior abdominal wall and rotated medially. (From El-Galley
RES, Keane TE. Kidneys, ureters, and bladders. In: Wood WC, Skandalakis JE, editors. Anatomic basis of tumor surgery.
St. Louis: Quality Medical Publishing; 1999; with permission.)
the renal vein and is ligated and divided. The back
surface of the renal vein should be inspected carefully
for any lumbar veins, which if present should be
ligated and divided. Then the renal vein should be
palpated for possible unsuspected thrombi, divided,
and ligated. Large tumors on either side frequently
develop parasitizing vessels, which are abnormal in
structure and frequently can lead to troublesome
bleeding if not ligated or clipped with great care.
Management of tumor extension in the vena cava
The presence of a solid mass in the vena cava
might represent tumor extension into the lumen,
blood thrombus, or less commonly tumor invasion
of the vena cava wall. Tumor extension into the vena
cava occurs in 4% to 10% of cases, and tumor-free
survival equivalent to survival of stage II is achieved
by complete removal of tumor extension in patients
without lymph node involvement [23]. Exploration of
the vena cava is a major procedure, and a complete
set of vascular instruments should be available. The
extent of the tumor extension into the vena cava
should be delineated preoperatively to help in plan-
ning the surgical approach. Right-sided renal tumors
with limited vena caval extension can be approached
with a right flank incision. A thoracoabdominal
incision is used for high right-sided tumor extension,
whereas a midline incision with or without a median
sternotomy extension is frequently required for
patients with left renal tumors and vena caval exten-
sion to the level of the hepatic veins or above.
Exposure of the retrohepatic vena cava is started
with division of the right triangular and coronary
ligaments of the liver and ligation of the small hepatic
(caudate) veins. The liver is then mobilized medially
to expose the vena cava, and a cardiac tourniquet is
applied around the vessel for temporary occlusion.
The contralateral renal vein and the infrarenal vena
cava also are occluded with a Rumel tourniquet.
Because about one fourth of the venous return in
the vena cava comes from the liver, clamping the
porta hepatis through the foramen of Winslow with a
noncrushing vascular clamp reduces the blood loss
remarkably. A cavotomy is made adjacent to the
hepatic veins and extended inferiorly to the origin
of the affected renal vein. A 20F Foley catheter with a
30-mL balloon is introduced into the vena cava, and
the balloon is inflated above the level of the thrombus
and withdrawn gently to extract the thrombus out of
the vena cava. In the rare occasion when the tumor
invades the wall of the vein, partial or complete
resection of the vein is considered. Air should be
evacuated from the vena cava before closure. A
Satinsky clamp is applied to the cavotomy, and the
edges of the vena cava are approximated gently with
Allis clamps. The tourniquet on the contralateral renal
vein and infrarenal vena cava and the clamp on the
porta hepatis are released, leaving the tourniquet on
the suprahepatic vena cava in place. The Satinsky
clamp is briefly vented to allow the air in the venal
cava to be evacuated; then the clamp is closed again,
and the last tourniquet on the vein is released. The
affected renal vein is transected flush with the vena
cava. The entire cavotomy is then closed with a
continuous 5-0 polypropylene suture.
Lymphadenectomy
The prognosis of renal cell carcinoma is mostly
affected by presence or absence of nodal metastasis.
Because of the position of the kidney just inferior to
the cisterna chylae, tumor spread from the renal
lymphatic vessels to the cisterna chylae and wide-
spread dissemination of the disease is common.
Curative lymphadenectomy is not possible in most
cases, and the value of lymphadenectomy is limited
to the diagnosis of lymph node involvement. Limited
dissection of the tissue around the junction of the
renal vessel to the nearest great vessel and resection
of the visible or palpable nodes is usually sufficient.
Nephroureterectomy
Transitional cell carcinoma of the calyces, pelvis,
or ureter usually is treated with nephroureterectomy,
provided the contralateral collecting system is normal
and no evidence exists of distant metastasis. Pre-
operative evaluation should include cystoscopy and
bilateral retrograde pyelography for better evaluation
of the collecting system. The operation can be per-
formed through a flank incision with downward
extension, or alternatively two separate incisions or
a midline incision can be made. The technique of
nephrectomy is the same. The ureter is mobilized
with blunt and sharp dissection down to its insertion
in the bladder. A cuff of the bladder must be removed
with the lower ureter because this is the most com-
mon site for tumor recurrence after nephroureterec-
tomy. The bladder is then closed in two layers with
2-0 chromic catgut sutures. A Foley catheter is left in
the bladder for drainage, and a drain in the pelvis
next to the suture line.
Partial nephrectomy
Renal cell carcinoma in a solitary functioning
kidney or bilateral tumors is best treated with partial
nephrectomy. Full preoperative evaluation should be
performed to confirm that the disease is localized.
The arterial anatomy of the affected kidney should be
studied carefully with preoperative angiography.
Flank incisions through the bed of the eleventh or
twelfth rib, with attempt to stay extrapleural and
extraperitoneal, provide an excellent exposure of the
peripheral renal vessels. Then the kidney is mobilized
within Gerotas fascia. Temporary occlusion of the
renal artery and surface cooling of the kidney with
iced slush during the procedure allow 60 minutes of
operating time without significant ischemic injury to
the kidney. For longer procedures the kidney should
be perfused with cold Collins solution through an
arterial catheter, which allows 3 hours for surgery.
Small polar or peripheral renal tumors may not
require renal artery occlusion, however, and the seg-
mental artery instead can be identified and divided.
Simple enucleation for malignant lesions should be
avoided even if the tumor looks well defined, because
of the probable presence of microscopic extensions of
these tumors beyond the pseudocapsule. Tumors of the
upper or lower pole of the kidney are best resected by
polar nephrectomy (guillotine resection), whereas
mid-renal tumors are resected with wedge resection.
Laparoscopic surgery
Over the past few years, laparoscopic surgery has
become more popular than the standard open radical
nephrectomy in many centers and is rapidly becoming
the standard of care in most patients with stage T1 and
T2 tumors (Fig. 8). Laparoscopic surgery offers
smaller cosmetic scars, better visualization, less blood
loss, minimal trauma, and equivalent tumor control to
open surgery, which is reflected in reduced morbidity
and increased patient satisfaction [24]. The contra-
indications to laparoscopic surgery include bulky
lymphadenopathy, IVC involvement, and extensive
perinephric visceral involvement. Unlike laparoscopic
radical nephrectomy, the laparoscopic technique for
partial nephrectomy is being developed. The increased
popularity of hand-assisted laparoscopy in the past few
years has reduced the learning curve for many sur-
geons and enabled the surgeons to deal with large
complicated tumors in safe and effective manner
[25,26].
Full laparoscopic radical nephrectomy is per-
formed through three to four laparoscopic ports and
hand-assisted laparoscopy is performed through a
hand port incision (6 to 8 cm) and two to three
instrument ports. The positions for these ports are
variable according the surgeons preference. The
abdomen is insufflated with CO
2
to a pressure of
25 mm hg. The peritoneum is incised at the Toldts
line to mobilize the colon and expose the Gerotas
fascia, which should be kept intact. On the right side,
the duodenum is mobilized medially and the liver is
retracted. The renal pedicle is then dissected and the
ureter is divided. The artery and vein are individually
clamped and divided with a laparoscopic stapler. On
the left side, the spleen and tail of the pancreas should
be mobilized medially by dividing the splenorenal
and splenophrenic ligaments. Then, the kidney is
dissected as on the right side. The kidney is extracted
through the hand port incision if hand-assisted lapa-
roscopy is chosen. If full laparoscopy is used, a
separate incision in the suprapubic area is made for
kidney extraction. Adrenalectomy used to be part of
radical nephrectomy in most patients. More recent
data, however, showed that adrenalectomy is not
necessary for lower pole tumors [2729].
Laparoscopic partial nephrectomy has been a
difficult procedure even for the experienced laparos-
copist. The laparoscopic approach is similar to radical
nephrectomy. After the kidney is dissected, the tumor
is located, preferably with the aid of intraoperative
ultrasound using a laparoscopic probe. The tumor is
then excised with a safety margin. Frozen sections are
obtained to ensure complete resection and hemostasis
is secured with electrocautery, fibrin glue, or sutures.
If the collecting system is opened, it should be closed
with water-tight sutures. The most difficult part of this
procedure is obtaining hemostasis. Desai et al [30]
have suggested a technique similar to open partial
nephrectomy. The kidney is dissected, the renal vessels
are dissected and clamped with laparoscopic Pull Dog
clamps, and the kidney is cooled with ice slush before
excising the tumor area.
An alternative to partial nephrectomy for small
renal tumors is the destruction of the tumor area with
freezing or radiofrequency ablation. These techniques Fig. 8. Laparoscopic view during radical nephrectomy.
may be performed percutaneously under CT guidance
or laparoscopically. Renal tumor ablation is discussed
elsewhere in this issue.
Results
Local disease control for localized renal tumors is
currently achieved in most patients who were treated
with radical or partial nephrectomy. If the tumor is
completely removed with negative margins, local
recurrence is rare. In most series local recurrence is
reported to occur in less than 2% of patients after
radical nephrectomy [31]. Similarly, in a large series
from Cleveland Clinic, local recurrence was reported
in 3.2% of patients who were treated with partial
nephrectomy; half of these patients had distant me-
tastasis in addition to local recurrence [32,33]. The
cancer-specific survival for patients who were treated
with radical nephrectomy was estimated to be 86.6%,
74%, 68.7%, and 63.8% for 1, 3, 7, and 10 years,
respectively [34]. Local recurrence in the absence of
metastasis is usually amenable to local excision.
Schrodter et al [35] reported on 16 patients who were
diagnosed with local recurrence after radical nephrec-
tomy. At surgical exploration, three patients were
found to have a false-positive CT, whereas the others
had true local recurrence of their tumors. After
complete resection of the recurrence, seven patients
died of metastatic disease after a mean survival of
23 months, and six patients were alive with a mean
follow-up of 53 months [35].
Involvement of the IVC with tumor thrombi occurs
in 4%to 10%of patients. Tumor excision is possible in
most of these patients with a survival range of 77% at
2 years and 55% at 5 years for patients who did have
other evidence of metastasis [36]. Bissada et al [37]
reported on the outcome of the management of renal
cell carcinoma with IVC extension in 54 patients.
Forty-eight patients did not have evidence of other
metastasis. Seven patients had invasion of the IVC
wall and required partial or complete resection of the
IVC. Of the 48 patients without evidence of metastasis
at surgery, the perioperative mortality rate was 2%.
Twenty-two patients (47%) were alive without evi-
dence of metastases, 4%developed solitary metastasis,
and 36% eventually developed multiple metastases.
The follow-up ranged from 25 to 144 months.
It is generally accepted that patients with lymph
node metastasis have a poor prognosis regardless of
the completeness of lymphadenectomy [38,39]. The
reported incidence of lymph node metastasis in renal
cancer patients is 13% [40]. The 5- and 10-year
survival for patients with renal cell carcinoma and
lymph node metastasis is 17% and 5%, respectively
[41]. Minervini et al [42] compared the survival for
renal cell carcinoma patients who had regional lym-
phadenectomy compared with patients who were
managed by radical nephrectomy alone. The 5-year
overall survival was similar whether or not lympha-
denectomy was performed: 79% for radical nephrec-
tomy alone and 78% for radical nephrectomy and
regional lymphadenectomy.
Since the introduction of laparoscopic radical and
total nephrectomy for renal tumor in June 1990, it has
been applied successfully worldwide to hundreds of
patients [43]. Recent data have shown this procedure
to produce cancer control identical to that of open
radical and total nephrectomy [44]. Although in most
centers the cost of the procedure remains higher than
open surgery, the patient benefits of decreased pain,
reduced hospitalization, less blood loss, and more
rapid convalescence seem to be universal [45]. At this
time, laparoscopic radical and total nephrectomy for
the treatment of renal tumors should become the new
standard of care in many centers [46].
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Percutaneous image-guided radiofrequency ablation
of renal malignancies
Ronald J. Zagoria, MD
Department of Radiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem,
NC 284011088, USA
The treatment of renal cell carcinoma (RCC) can
be a vexing problem. Although advanced disease
does not respond well to therapy and the prognosis
remains extremely poor, the rate of RCC diagnosis
has increased substantially [1]. In the year 2002, there
were over 30,000 new cases of RCC diagnosed in the
United States [2]. This equates to greater than a 100%
increase in the incidence of RCC diagnosed in the
United States since 1950. Most of this increase has
occurred because of the diagnosis of small, localized
tumors detected incidentally in asymptomatic patients
imaged for other reasons [3].
Radical nephrectomy has long been considered
the standard treatment for localized RCC. Mean-
while, renal-sparing surgery has grown in popularity
and the techniques have been refined. Studies com-
paring surgical techniques have shown that open
partial nephrectomy is as effective in curing small,
localized RCCs as radical nephrectomy [4,5]. This
indicates that complete eradication of a renal tumor
can result in cure rates comparable with those of
treatment using complete removal of a kidney con-
taining a tumor. Advances in imaging and thermal
ablation techniques, combined with the theory that
tumor destruction yields results comparable with
tumor resection, have led to increased interest in
image-guided, minimally invasive percutaneous ther-
mal ablative techniques for the treatment of RCC.
There is substantial experience in treatment of neo-
plasms using both radiofrequency ablation (RFA)
[69], which causes tumor destruction by heating,
and cryotherapy, which destroys tumors using freez-
ing [1013]. Most cryotherapy devices require a
sizeable portal to introduce the ablation device.
Cryotherapy usually requires laparoscopic or open
surgery. Although radiofrequency devices can be
introduced intraoperatively during an open procedure,
most experience with this technique has used percu-
taneous image-guided procedures.
Radiofrequency ablation uses the introduction of a
high-frequency, alternating current within the targeted
tissue [7]. Emission of this energy in a patient to
whom grounding pads have been applied results in
concentrated ionic agitation in tissues nearby the site
of energy transmission. This ionic agitation in turn
results in the generation of heat. This type of thermal
ablative technique is akin to microwave heating used
in everyday applications. When living human tissues
are heated above 49C immediate cell death occurs
[14]. The cell death is induced by denaturation of
protein, melting of cell membranes, and thermal
destruction of cytoplasm [14]. This results in direct
cytodestruction of the affected cells. Some cells are
destroyed at temperatures below 49C, but some cells
can survive temperatures approaching 49C. For per-
cutaneous image-guided RFA the energy is delivered
into the target tissue through needle-shaped probes.
Currently available RFA electrodes range in diameter
from 15 to 17 gauge. Three radiofrequency devices
approved by the Food and Drug Administration are
available in the United States. Each of these uses a
different strategy to maximize the size of thermal
ablation. Each device also uses a slightly different
approach to energy delivery for thermal destruction.
All of the available radiofrequency devices use genera-
tors that deliver between 150 and 200 W of energy.
This represents an increase over earlier generators that
delivered 50 to 125 W of energy. This lower energy
proved suboptimal. The next generation of radio-
doi:10.1016/S0033-8389(03)00074-5
E-mail address: rzagoria@wfubmc.edu
Radiol Clin N Am 41 (2003) 10671075
frequency generators may deliver even higher levels of
energy to increase the area of the treatment zone.
The maximum size of the treatment zone for in
vivo treatment of renal tumors has been shown to
approximate a 5 cm sphere for a single RFA [7]. The
size of the zone of ablation is often smaller than this
maximum, and usually averages between a 3- and
4-cm sphere [14]. The maximum size of the treatment
zone is increased by inducing ischemia, or in devas-
cularized tissue. Alternatively flowing blood, large
fluid-containing spaces, or circulating air can de-
crease the effective size of the treatment zone [14].
When RFA of renal tumors is performed using a
percutaneous technique, imaging guidance is required.
This is usually done using CTscanning or sonography.
The technique of placing the electrode is analogous to
R.J. Zagoria / Radiol Clin N Am 41 (2003) 10671075 1068
that of performing an image-guided biopsy of a renal
mass (Fig. 1). The actual treatment of the tumor can be
quite painful; more sedation is required than for a
standard needle biopsy. Most cases are performed with
conscious sedation and local anesthesia [7].
Percutaneous RFA has been applied for the pri-
mary treatment of RCC in nonoperative patients
[6,8,9], for the treatment of local recurrences of
RCC that are deemed inoperable [15], and also for
the treatment of isolated metastases from RCC
primaries [1]. At the authors institution they per-
formed a phase two clinical trial using the in vivo
application of RFA of renal parenchymal tumors
immediately before nephrectomy [7]. Biopsies were
obtained of all tumors before RFA. The ablation was
performed intraoperatively using ultrasound guidance.
In this study, a Radionics cool-tip radiofrequency
system (Radionics, Burlington, MA), which consists
of the CC-1 Cosman Coagulator, the cool-tip treatment
electrode, and a peristaltic perfusion pump, was used.
Following tumor biopsy a single RFA of 12 minutes
duration was performed using the automatic output
control setting of this radiofrequency generator. Fol-
lowing the single RFA a nephrectomy was performed
and the tumor was evaluated histologically using both
standard and vital stains.
The tumors treated in this study were all deter-
mined to be RCCs (nine clear cell carcinomas and
one papillary carcinoma). The tumors ranged in size
from 1.4 to 8 cm in diameter. The average tumor size
in this series was 3.2 cm in diameter. Eight of the
10 tumors were completely destroyed with no identi-
fiable viable tumor remaining after a single 12-minute
ablation. Two tumors, 1.4 and 8 cm in diameter,
were incompletely treated with a single ablation. The
1.4-cm tumor had approximately 70% destruction but
the temperature in the tissue immediately following the
ablation was below the target temperature of 49C or
higher. A large segment of the 8-cm tumor was
destroyed with viable tumor remaining at the periph-
ery. In all cases no skip areas of viable tumor were
identified in the necrotic regions. Evaluation of the
surrounding kidney following nephrectomy demon-
strated that a margin of treated, nonviable kidney tissue
was identified in all eight of the completely ablated
tumors. The treatment margin ranged from 2 to 13 mm
in thickness. In no case was the rim of destroyed
normal kidney greater than 13 mm in diameter.
The results of this study are encouraging and indi-
cate that in vivo treatment of small RCCs is feasible,
although clearly some tumors require greater than
one 12-minute RFA treatment for complete destruc-
tion of the tumor. Based on this study it seems that
only a small amount of adjacent normal kidney is
destroyed, suggesting that little diminution in renal
function results when using this technique.
In 1992, the first published report using radio-
frequency tissue ablation was released. This used
RFA for the treatment of hepatic tissues [16]. In
1997, the use of RFA to produce extensive necrosis
of kidney tumors in humans was reported [17]. In
1998, a case report was published reporting the first
case where percutaneous RFA was used for the
complete treatment of an RCC in a human under
ultrasound guidance [18].
Since those reports were published, several other
larger studies using RFA for the treatment of renal
tumors have been published [69]. One group has
used RFA ablation in a porcine model and found that
RFA of renal tumors results in necrosis of the ablated
tumor and surrounding renal parenchyma with no
evidence of collecting system damage [19]. One
group has reported their experience treating nine
renal tumors in eight patients using percutaneous
RFA [6]. With a follow-up of just over 10 months
in these eight patients, seven of the nine tumors were
completely free of demonstrable enhancement on CT
scans suggesting complete ablation of these seven
tumors. Within this group of tumors, five of five
exophytic tumors were rendered completely non-
enhancing, whereas only one of three central RCCs
was completely free of enhancement on follow-up
Fig. 1. The technique of radiofrequency ablation (RFA) of renal malignancies in an elderly man with multiple co-morbidities and
an enlarging biopsy-proved renal cell carcinoma (RCC). (A) Unenhanced CT shows the 3-cm RCC (arrow) extending from the
upper pole of the right kidney. This measured 22 HU on this scan. (B) Following contrast material injection this tumor enhanced
to 99 HU on this scan obtained several months before the ablation procedure. (C) CT scan obtained during the RFA procedure
shows the patient in a prone position with the percutaneous radiofrequency electrode (arrow) placed so the tip is bisecting the
tumor. There is a small amount of blood (arrowhead) in the perinephric space, a common finding seen during this procedure. A
22-gauge needle is seen adjacent to the electrode. This was used to target the tumor using a tandem technique. (D) An
unenhanced CT scan obtained 14 months after the ablation shows the ablated RCC is slightly hyperdense compared with the
kidney. It measured 33 HU on this scan. There is a small amount of perinephric stranding seen adjacent to the kidney, an
expected finding following percutaneous RFA. (E) Following contrast material injection the mass shows no enhancement
measuring 35 HU. Lack of enhancement and stability of the tumor size strongly suggests complete tumor destruction.
CT. All three RCCs smaller than 3 cm were rendered
completely nonenhancing, whereas four of six RCCs
greater than 3 cm were completely ablated. These
authors reported that multiple ablations within a
single treatment session, or repeated treatment ses-
sions, are often needed to destroy RCCs completely,
particularly those located centrally. Although micro-
scopic hematuria was common in the 24-hour period
immediately following ablation there were no serious
complications in any of these eight patients.
In one larger series 24 RCCs in 21 patients with
von Hippel-Lindau disease or with familial papillary
Fig. 2. MR imaging of an RCC before and after percutaneous RFA showing residual viable tumor requiring repeat ablation.
(A) T1-weighted MR image before gadolinium injection shows the 3-cm RCC arising from the upper pole of the right kidney.
(B) T1-weighted MR image at the same level following gadolinium injection shows marked heterogeneous enhancement of the
tumor. (C) CT scan obtained during the RFA procedure shows the patient in a prone position with the percutaneous
radiofrequency electrode (arrow) placed so the tip is bisecting the tumor in the right kidney. There is a small amount of blood
(arrowhead) in the perinephric space from this procedure. (D) T1-weighted MR image before gadolinium injection obtained
4 months after the percutaneous renal tumor ablation shows heterogeneous increased signal in much of the tumor. This is
commonly seen and is believed caused by coagulative necrosis in the ablated tumor. (E) Following gadolinium injection this
T1-weighted MR image with fat saturation shows a small area of enhancement (arrows) in the anterior aspect of the otherwise
nonenhancing tumor. This enhancement was interpreted as an area of residual viable tumor. The perinephric hemorrhage that
occurred during the ablation is again seen. ( F) CT scan obtained during the second RFA procedure shows the patient in a prone
position with the percutaneous radiofrequency electrode (arrow) placed so the tip is located in the area where viable tumor was
demonstrated on the MR image shown in Fig. 2E. ( G) This T1-weighted MR image with fat saturation and following gadolinium
injection was obtained 4 months after the second percutaneous ablation. No enhancement was detectable within the treated tumor
suggesting complete tumor destruction.
RCCs were treated with percutaneous RFA [8]. At a
2-month follow-up, 19 of the 24 treated tumors
demonstrated no evidence of contrast enhancement
on CT imaging. The remaining five tumors demon-
strated some persistent enhancement. There were no
serious complications in this series of patients and all
of these patients were treated on an outpatient basis.
Contrast-infused CT and MR imaging have been
used to detect viable tumor following renal tumor
RFA. In one in vivo study there were no skip areas
where viable tumor survived within the ablation zone
[7], so these should be reliable methods for following
these patients. In a second in vivo study using a
different RFA device, however, 5% to 10% viable
tumor remained in most tumors [20]. This group also
found that contrast enhancement could not always be
detected with CT in areas where viable tumor was
histologically demonstrated following nephrectomy
[20]. This suggests the possibility that lack of contrast
enhancement may overestimate tumor destruction
caused by RFA.
In many cases coagulative necrosis within the
treated area often has a higher baseline attenuation
and high signal on T1 and T2 sequences when
imaged with CT or MR imaging, respectively
(see Fig. 1; Fig. 2). This should not be misinterpreted
as viable neoplasm. Areas of enhancement should be
viewed, however, as residual viable tumor and re-
treated (see Fig. 2).
There is a growing body of knowledge regarding
percutaneous RFA of RCCs. It seems this technique
has a low complication rate, preserves renal function,
is well tolerated by patients, and can result in com-
plete destruction of renal tumors 5 cm or smaller in
most patients (Fig. 3). In some patients viable tumor
can be demonstrated following one session of RFA
(see Fig. 2). This may require further ablation ses-
sions (see Fig. 2). Repeated RFA ablations have been
performed in many patients with renal tumors [6] and
routinely in patients with hepatic tumors, where RFA
experience is more extensive than in the kidney.
Repeat RFA for treatment of residual tumor seems
Fig. 2 (continued).
to be a safe procedure without a risk greater than with
primary RFA. It seems that there is little renal damage
associated with RFA. Even in the treatment of central
tumors the development of clinically important pel-
vicalyceal damage has not been reported. Because in
vivo studies have demonstrated only a small amount
of kidney destruction in the area surrounding the
tumor, renal function should remain nearly intact
following this procedure. Obviously, there is limited
information on this procedure and at this time it
should be reserved for patients for whom some
treatment is indicated, but who are not surgical
candidates. Long-term results for this procedure have
yet to be reported.
Radiofrequency ablation also has been used for
other applications in treating RCCs. A single case
report described the successful use of RFA to treat
intractable gross hematuria resulting froma large RCC
[21]. In this case, the life-threatening hematuria failed
to resolve following standard techniques including
renal embolization therapy. RFAwas performed with-
out complications and the patient remained free of
hematuria for a prolonged period of time. In this case,
RFA was used for palliation of symptoms from RCC
rather than as a curative technique.
Radiofrequency ablation also has been used for
the treatment of recurrent and metastatic RCC. There
have only been anecdotal successes reported; this
technique must be viewed as preliminary, but prom-
ising. At the authors institution they have used RFA
to treat unresectable local recurrence from RCC in
two patients. In one patient the recurrence was
extremely large and because of impingement on the
neural foramina was debilitating. Extensive RFA
treatment was performed resulting in a marked de-
crease in symptoms and improved quality of life. In
an additional case [15], recurrence of RCC in the
surgical bed occurred (Fig. 4). The recurrence abutted
the abdominal aorta and was believed to be unresect-
able (see Fig. 4). The recurrence was unresponsive to
immunotherapy and chemotherapy and continued to
grow during CT surveillance monitoring. A single
session of percutaneous CT-guided RFA was per-
formed on this recurrent tumor (see Fig. 4). An
immediate contrast-infused CT demonstrated no evi-
dence of complications. No enhancing tumor could
be demonstrated immediately following the RFA
treatment. This patient has remained free of identifi-
able disease (see Fig. 4) for over 16 months [15]. The
treated area of recurrence has decreased in volume
with no evidence of enhancing, viable tumor. In these
two cases RFA seemed to be helpful in the treatment
of locally recurrent RCC. This is a very promising
area for the use of image-guided RFA therapy.
In addition, in some cases patients with distant
metastases from RCC may experience prolonged
survival with eradication of the metastases [22]. This
well-documented phenomenon has most often been
seen in patients following metastasectomy of a small
number of pulmonary metastases from RCC [22]. In
general, patients with metastatic RCC have an ex-
tremely poor prognosis with nearly no 5-year sur-
vivals following diagnosis [23]. Metastatic RCC is
nearly always incurable with systemic immuno-
therapy or chemotherapy. Even though some case
reports show prolonged tumor remission following
metastasectomy, surgical resection of pulmonary
metastases uncommonly results in improved progno-
Fig. 3. Successful ablation of a larger, centrally located RCC. (A) Unenhanced CTscan shows a 5 cm3 cmtumor (arrow) located
centrally in the left kidney. (B) Contrast-enhanced CTobtained immediately following percutaneous ablation shows heterogeneity
of the treated tumor without enhancement. There is perinephric hemorrhage present resulting from the ablation procedure.
sis for RCC patients [22]; surgeons are often reluc-
tant to perform this procedure. This may be another
opportunity for the use of image-guided percutane-
ous RFA treatment. In one published report a patient
with two pulmonary metastases from a previously
resected RCC was successfully treated with percuta-
neous CT-guided RFA [24]. In this patient, the two
pulmonary metastases were peripherally located in
the right lower lobe of the lung (Fig. 5). At 18-month
follow-up, this patient has not received any other
treatment for his RCC, but remains free of detectable
disease (see Fig. 5). The use of image-guided RFA
for treatment of isolated metastases from RCC as in
this reported case is promising, but at this point it
should be reserved as a last resort in nonoperative
candidates until larger studies can demonstrate its
efficacy compared with surgery. Percutaneous RFA
has been used to treat neoplasms in sites where RCC
commonly metastasizes, however, including the
lungs, liver, and the skeleton. The morbidity associ-
ated with this type of treatment based on experience
with other neoplasms in these locations is very low
with serious complications occurring in less than 5%
of treated patients [25]. Because of the low morbidity
and extremely low risk of mortality associated with
image-guided percutaneous RFA, this treatment may
Fig. 4. Percutaneous radiofrequency of a recurrent RCC. (A) Contrast-enhanced CT scan shows an enhancing mass (arrow)
abutting the aorta and the superior mesenteric artery in this man who previously had a left nephrectomy for RCC. A biopsy of
this mass was found to be recurrent RCC. (B) CT scan obtained during the RFA procedure shows the patient in a prone position
with the percutaneous radiofrequency electrode (arrow) placed so the tip is bisecting the tumor. This scan also shows a small
amount of gas in the tumor adjacent to the electrode. This common finding is attributable to necrosis and vaporization of tissue
induced by the radiofrequency energy. (C) Contrast-enhanced CT scan obtained 10 months after the ablation procedure shows
that tumor has decreased in size and no enhancement, consistent with complete tumor destruction. The superior mesenteric artery
and aorta remain widely patent.
be considered for patients who have failed systemic
therapy, and in whom the potential benefits of
surgery seem to be outweighed by the risk of
substantial morbidity resulting from successful me-
tastasis resection.
Summary
There is a growing body of experience supporting
the use of image-guided RFA for the treatment of
primary RCC. Because surgical resection is a tech-
nique with low mortality, and a proved success rate
that is high, this must remain standard therapy for
patients with potentially curable RCC. Some patients
with low-stage RCC, however, may not be surgical
candidates. Image-guided RFA is an option for treat-
ment of these patients. In addition, image-guided
RFA shows promise for the successful care of other
patients with RCC. In particular, RFA has been used
successfully for the treatment of intractable hematuria
resulting from an RCC; local recurrences of RCC,
both for attempted cure and for palliation of symp-
toms; and finally for the treatment of isolated metas-
tases from RCC. As with the treatment of primary
RCC, the data remain limited for these applications.
Fig. 5. Percutaneous RFA of pulmonary metastasis from RCC. (A) CT shows one of two pulmonary metastases in this patient
with a history of RCC. These biopsy-proved metastases were refractory to systemic therapy. (B) CT scan obtained during the
RFA procedure shows the patient in a prone position with the percutaneous radiofrequency electrode placed so the tip is bisecting
the tumor in the right lung. (C) CTscan obtained 29 months after the ablation procedure shows a small area of scarring where the
tumor had been located. There was no evidence of viable tumor in either of the treated lung metastases.
This technique should be reserved until after standard
therapies have been exhausted. It seems likely that
some form of image-guided percutaneous tumor
therapy, such as RFA, will become an alternative
treatment modality in some patients with potentially
curable RCC.
References
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Index
Note: Page numbers of article titles are in boldface type.
A
Acceleration index, in color Doppler imaging, in
infants, 933934
ACE inhibitor renal scintigraphy, of hypertension, in
infants, 939941
of renal artery stenosis, 913914
Aneurysms, renal artery, and hypertension, 922923
Angiography, CT. See CT angiography.
intra-arterial, of renal artery stenosis, 919
MR. See MR angiography.
of hypertension, in infants, 935937
of renal trauma, 1019
Angiomyolipomas, imaging of, ultrasound contrast
agents in, 963965
Angioplasty, for renal artery stenosis, 919, 921
Arteriography, intra-arterial digital subtraction, of
hypertension, in infants, 936
Arteriovenous communications, and hypertension,
923924
Atherosclerotic disease, and renal artery stenosis, 911
B
Birt-Hogg-Dube syndrome, imaging of, 10441045
Breathhold imaging, of kidneys, 880, 882
C
Calcifications, renal, CT of, 867
Captopril, in MR imaging, of renal function,
10061008
Catheter-associated thromboembolism, angiography
of, in infants, 937
ultrasonography of, in infants, 933
Chromosome 3, translocation of, and hereditary renal
cancer, 1046
Color Doppler imaging, of hypertension, in infants,
933935
Computed tomography, of kidneys. See Kidneys.
of renal trauma. See Renal trauma.
of urinary lithiasis. See Urinary lithiasis.
of von Hippel-Lindau disease, 1040
Contusions, renal, imaging of, 10261027
Crossing vessels, renal, CT of, 871
Cryotherapy, for von Hippel-Lindau disease,
10401041
CT angiography, of hypertension, in infants, 941
of kidneys, versus CT, 866867
of renal masses, 870871
CT urography, of hematuria, 944, 946953
technique for, 944, 946953
excretory-phase CT with multiplanar
reformation, 951953
scanned projection radiographic
technique, 948
Cyclosporine toxicity, and renal transplant
dysfunction, MR imaging of, 1013
Cystic masses, renal, imaging of, ultrasound contrast
agents in, 965968
D
Diabetic nephropathy, and hypertension, 925
Diagnostic peritoneal lavage, for renal trauma, 1020
Dissection, renal artery, and hypertension, 923
Doppler ultrasonography, of renal artery stenosis,
914, 916917
doi:10.1016/S0033-8389(03)00131-3
Radiol Clin N Am 41 (2003) 10771082
F
Familial renal cancer, imaging of, 1046
Familial renal oncocytomas, imaging of, 1045
Fibroids, uterine, hereditary leiomyoma renal cell
carcinoma and, 1043
Fibromuscular dysplasia, and renal artery stenosis,
911912
G
Glomerular filtration rate, MR imaging of,
10041006
Glomerulonephritis, and hypertension, 924925
Gray-scale ultrasonography, in infants, 932933
H
Harmonic imaging, of kidneys, 962
Hematomas, perinephric, imaging of, 1027
subcapsular, and hypertension, 926927
imaging of, 1027
Hematuria, CT of, 867
CT urography of. See CT urography.
MR urography of. See MR urography.
radiofrequency ablation of, 1068
Hereditary renal cancer, 10351049
Birt-Hogg-Dube syndrome, 10441045
familial renal cancer, 1046
familial renal oncocytomas, 1045
histologic subtypes of, 1035, 1037
leiomyoma renal cell carcinoma, 10421043
medullary carcinoma, 1045
papillary renal carcinoma, 10411042
translocation of chromosome 3, 1046
tuberous sclerosis, 1046
von Hippel-Lindau disease, 10371041
cryotherapy for, 10401041
CT of, 1040
MR imaging of, 1040
nephron-sparing surgery for, 1040
Hydronephrosis, MR urography of, 10081009
Hypertension, in infants, 929942
angiography of, 935937
CT angiography of, 941
diagnosis of, clinical aspects of, 929930
imaging of, etiology and, 931
nuclear medicine studies of, 937941
ultrasonography of, 931935
renal causes of, 909928
arteriovenous communications, 923924
chronic pyelonephritis, 925926
diabetic nephropathy, 925
evaluation of, 927
glomerulonephritis, 924925
midaortic syndrome, 922
nephroslcerosis, 925
neurofibromatosis, 921922
polyarteritis nodosa, 923
polycystic kidney disease, 926
posttraumatic stenosis, 924
renal artery aneurysm and dissection, 922923
renal artery stenosis, 909914, 916919, 921
ACE inhibitor renal scintigraphy of,
913914
atherosclerotic disease in, 911
CT angiography of, 918919
Doppler ultrasonography of, 914, 916917
fibromuscular dysplasia in, 911912
functional versus anatomic imaging of, 913
intra-arterial angiography of, 919
management of, 919, 921
MR angiography of, 917918
subcapsular hematomas, 926927
Takayasua arteritis, 921
tumors, 926
I
Infarctions, renal, imaging of, 1028
ultrasound contrast agents in, 971972
Intra-arterial angiography, of renal artery
stenosis, 919
Intra-arterial digital subtraction arteriography, of
hypertension, in infants, 936
Intravenous urography, of renal trauma, 1018
J
Juxtaglomerular cell tumors, and hypertension, 926
K
Kidneys, CT of, 863875
compression for distention in, 874
contrast in, 864866
concentration and total dosage, 864865
high-concentration contrast, 865866
Index / Radiol Clin N Am 41 (2003) 10771082 1078
injection rates, 865
oral contrast versus water, 865
detectors in, 864
for crossing vessels, 871
for renal masses, 868871
characterization of, 869
delayed imaging in, 870
nephrographic phase in, 870
staging of, 869870
versus CT angiography, 870871
for transplant donor evaluation, 871
for trauma, 868
for urolithiasis, 867868
molecular imaging in, 874
pitch in, 863864
radiation dosage in, 872873
in children, 872, 873
in pregnancy, 872873
reconstruction in, 864
versus CT angiography, 866867
volumetric acquisition in, 873874
devascularized, imaging of, 1030
imaging of, ultrasound contrast agents in.
See Ultrasound contrast agents.
MR imaging of, 877907
breathhold technique for, 880, 882
contrast-enhanced dynamic imaging, 895898
applications of, 895898
contrast media and volume in, 898
contrast rate in, 898
flush volume and rate in, 898
power injector in, 898
timing of, 898
flow-sensitive imaging, 894895
for renal arteries, 878880
versus MR angiography, 878880
for renal masses, 877878
for renal veins, 880
for urothelial tumors, 878
image processing in, 898, 900901
subtraction in, 898, 900
three-dimensional reconstruction in,
900901
non-breathhold technique for, 882884
coils and parallel imaging in, 883884
fast acquisitions in, 882883
motion compensation strategies in, 883
T1-weighted imaging, 886888, 890894
gradient-echo sequences in, 886888
in-phase and opposed phase, 888, 890891
spin-echo sequences in, 892
three-dimensional, 892894
two- versus three-dimensional, 892
T2-weighted imaging, 884886
echo-train imaging in, 885886
Half-Fourier reconstruction in, 886
spin echo sequences in, 884885
shattered, imaging of, 10281029
L
Lacerations, renal, imaging of, 1027
Laparoscopic nephrectomy, for renal tumors,
1060, 1061
Leiomyoma renal cell carcinoma, hereditary, imaging
of, 10421043
Leiomyomas, malignant potential of, 1043
Leiomyosarcomas, malignant potential of, 1043
Lithiasis, urinary. See Urinary lithiasis.
Lymphadenectomy, for renal tumors, 1059, 1061
M
Magnetic resonance imaging, of kidneys.
See Kidneys.
of renal function. See Renal function.
of urinary lithiasis, versus CT, 988, 990
Medullary carcinoma, imaging of, 1045
Metastatic disease, from renal cell carcinoma,
Midaortic syndrome, and hypertension, 922
Molecular imaging, of kidneys, 874
MR angiography, of renal arteries, 878880
three-dimensional, of kidneys, 892894
MR urography, of hematuria, 953957
gadolinium-enhanced T1-weighted, 955957
heavily T2-weighted, 953955
of hydronephrosis, 10081009
N
Nephrectomy, partial, for renal tumors, 10591061
laparoscopic, for renal tumors, 1060, 1061
radical, for renal tumors, 10571058, 10601061
Nephron-sparing surgery, for von Hippel-Lindau
disease, 1040
Nephropathy, diabetic, and hypertension, 925
Nephrosclerosis, and hypertension, 925
Nephroureterectomy, for renal tumors, 1059
Neurofibromatosis, and hypertension, 921922
Non-breathhold imaging, of kidneys. See Kidneys,
MR imaging of.
Nuclear medicine studies, of hypertension, in infants,
937941
O
Oncocytomas, familial renal, imaging of, 1045
P
Papillary renal carcinoma, hereditary, imaging of,
10411042
Partial nephrectomy, for renal tumors, 10591061
Percutaneous transluminal renal artery angioplasty,
for renal artery stenosis, 919, 921
Perinephric hematomas, imaging of, 1027
Phleboliths, versus urinary lithiasis, 980, 982983
Plain films, of renal trauma, 1018
Polyarteritis nodosa, and hypertension, 923
Polycystic kidney disease, and hypertension, 926
Posttraumatic stenosis, of renal artery, and hyperten-
sion, 924
Pregnancy, radiation dosage in, 872873
Pseudotumors, renal, imaging of, ultrasound contrast
agents in, 968
Pyelography, retrograde, of renal trauma, 1020
Pyelonephritis, chronic, and hypertension, 925926
imaging of, ultrasound contrast agents in,
972973
R
Radical nephrectomy, for renal tumors, 10571058,
10601061
Radiofrequency ablation, of renal cell carcinoma. See
Renal cell carcinoma.
Renal arteries, MR imaging of, 878880
Renal artery aneurysms, and hypertension,
922923
Renal artery dissection, and hypertension, 923
Renal artery stenosis, and hypertension.
See Hypertension.
imaging of, ultrasound contrast agents in, 971
Renal artery thrombosis, ultrasonography of, in
infants, 932
Renal cancer, hereditary. See Hereditary
renal cancer.
Renal cell carcinoma, imaging of, ultrasound contrast
agents in, 963
clinical studies of, 10651067
devices for, 10631064
for distant metastases, 1068-1070
for recurrent disease, 1068
treatment zone in, 1064
tumor size and, 1065
viable tumor following, 1067
Renal cystic diseases, ultrasonography of, in
infants, 932
Renal function, MR imaging of, 9991015
captopril in, 10061008
contrast quantification in, 10001001
for hydronephrosis, 10081009
for renal transplant evaluation, 10091013
gadolinium dose optimization in, 1001
glomerular filtration rate in, 10041006
image postprocessing in, 10011002
perfusion imaging in, 10021004
arterial spin labeling technique for, 1003
blood oxygen level-dependent imaging in,
10031004
extravascular contrast agents in, 10021003
intravascular contrast agents in, 1003
Renal masses, CT of. See Kidneys, CT of.
cystic, imaging of, ultrasound contrast agents in,
965968
indeterminate, imaging of, ultrasound contrast
agents in, 969, 971
MR imaging of, 877878
Renal perfusion, imaging of, ultrasound contrast
agents in, 971973
Renal transplantation, donor evaluation for, CT
in, 871
postoperative evaluation of, MR imaging in,
10091013
Renal trauma, classification of, 10241030
grade 1, 10261027
grade 4, 10271028
grade 5, 10281030
grades 2 and 3, 1027
vascular contrast extravasation in, 10303031
imaging of, 10171033
angiography in, 1019
CT in, 868, 10211024
contrast in, 1021
interpretation of, 10231024
technique for, 10211023
diagnostic peritoneal lavage in, 1020
intravenous urography in, 1018
MR imaging in, 1021
nuclear medicine studies in, 1021
patient selection for, 10171018
plain films in, 1018
retrograde pyelography in, 1020
ultrasonography in, 1019
ultrasound contrast agents in, 973
Renal tumors, cystic, 1052
solid, 1052
surgical management of, 10511062
anatomy in, 10521056
blood supply, 10541056
lymphatic drainage, 1056
laparoscopic, 1060, 1061
lymphadenectomy in, 1059, 1061
nephroureterectomy in, 1059
partial nephrectomy in, 10591061
radical nephrectomy in, 10571058,
10601061
surgical approaches in, 1056
vena caval extension and, 10581059
versus pseudotumors, 1052
Renal vein injuries, imaging of, 1030
Renal vein thrombosis, ultrasonography of, in
infants, 932
Renal veins, MR imaging of, 880
Reninomas, and hypertension, 926
Resistive index, in color Doppler imaging, in infants,
933934
Retrograde pyelography, of renal trauma, 1020
S
Sickle cell trait, medullary carcinoma in, 1045
Subcapsular hematomas, and hypertension, 926927
imaging of, 1027
T
Takayasus arteritis, and hypertension, 921
Thromboembolism, catheter-associated, angiography
of, in infants, 937
Thrombosis, renal artery, ultrasonography of, in
infants, 932
renal vein, ultrasonography of, in infants, 932
Trauma, renal. See Renal trauma.
Tuberous sclerosis, and hereditary renal
cancer, 1046
U
Ultrasonography, Doppler, of renal artery stenosis,
914, 916917
of hypertension, in infants, 931935
of urinary lithiasis, versus CT, 988
Ultrasound contrast agents, in renal imaging,
961976
intraoperative, 973
microbubble-specific techniques for, 962963
of angiomyolipomas, 963965
of cystic masses, 965968
of indeterminate masses, 969, 971
of infarcts, 971972
of pseudotumors, 968
of pyelonephritis, 972973
of renal cell carcinoma, 963
of renal perfusion, 971973
of trauma, 973
Ureteral complications, of renal transplantation, MR
imaging of, 1013
Ureteropelvic junction injuries, imaging of,
10291030
Urinary lithiasis, CT of, 977997
advantages and disadvantages of, 977978
interpretation of, 980, 982987
radiation in, 987988
technique for, 978980
versus MR imaging, 988, 990
versus ultrasonography, 988
versus phleboliths, 980, 982983
Urography, CT. See CT urography.
intravenous, of renal trauma, 1018
MR. See MR urography.
Urolithiasis, CT of, 867868, 872
Urothelial tumors, MR imaging of, 878
Uterine fibroids, hereditary leiomyoma renal cell
carcinoma and, 1043
V
Vena cava, renal tumor extension into, 10581059
von Hippel-Lindau disease. See Hereditary
renal cancer.

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zdemir H, Akpek S, Gurel K, Kapucu O,

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