Quantitative renal magnetic resonance imaging: magnetic resonance urography

Unique Variants of Megacalycosis on Magnetic Resonance Urography

OBJECTIVE

To present a unique set of patients diagnosed with megacalycosis by magnetic resonance urography (MRU) to re-evaluate the definition of megacalycosis and provide a new perspective on diagnosis and treatment.

MATERIALS AND METHODS

A retrospective chart review of patients with megacalycosis as diagnosed by MRU was conducted. MRU was performed to determine the presence of obstruction, further visualize renal anatomy, and clarify the presence of megacalycosis. Patients who were asymptomatic and demonstrated no evidence of obstruction were managed with long-term observation through renal bladder ultrasonography, and symptomatic patients who showed evidence of obstruction (crossing vessels, abnormal renal transit time, or disparity in differential renal function of <40%) were treated surgically with a dismembered Anderson-Hynes pyeloplasty.

RESULTS

Thirteen cases of megacalycosis were identified as diagnosed by MRU at our institution between 2007 and 2020. In 7 patients (54%), MRU revealed the simultaneous occurrence of obstruction and megacalycosis. In patients with obstruction (N = 7), surgical intervention was required to correct the obstruction via robotic pyeloplasty. In patients without obstruction (N = 6), conservative management was performed to monitor megacalycosis through long-term follow-up via routine ultrasounds.

CONCLUSION

While megacalycosis has historically referred to the non-obstructive dilatation of the renal calyces, our study presents 7 cases of obstruction occurring simultaneously with megacalycosis as diagnosed by MRU. By expanding the designation of megacalycosis to include patients with obstruction, surgical treatment can be explored to prevent future renal colic and/or renal deterioration in those patients.

Prognostic value of novel cardiovascular magnetic resonance transit times beyond the pulmonary circulation in patients with ventricular dysfunction

OBJECTIVES

To evaluate the prognostic value of transit time (TT) assessment in the systemic circulation and organ perfusion in patients with ventricular dysfunction (VD). The primary endpoint was defined as death, heart failure admission, or ventricular arrhythmias, and the secondary endpoint was worsening renal function.

METHODS

A retrospective study on 139 patients who underwent cardiac magnetic resonance for VD evaluation and 50 controls. TT was measured as peak-to-peak time in signal intensity over time curves obtained at different stages of circulation (right cavities, left cavities, aorta, and peripheral organs) from first-pass perfusion images. Outcomes were monitored over a median follow-up of 15 months.

RESULTS

A total of 139 patients were included (84% male, age 63 [57-70] years). Patients exhibited significantly prolonged TT compared to controls, with in-patients showing longer times than outpatients. Among the 29 patients reaching the primary endpoint, both PTT and STT were significantly prolonged (PTT: 9.75 s vs 13.4 s, p < 0.01; STT: 4.77 s vs 7.00 s, p < 0.01). Concurrent prolongation of PTT (> 10 s) and STT (> 5 s) was associated with a higher event probability (42.3%), compared to isolated abnormalities (6.3% for PTT, 6.7% for STT). Multivariate analysis revealed that combined PTT and STT alteration independently predicted the combined endpoint (HR IC 95%: 8.685 (2.415-31.236), p = 0.001). Prolonged RPT was independently associated with renal function deterioration (OR IC 95%: 1.129 (1.015-1.256), p = 0.024).

CONCLUSIONS

Evaluation of TT beyond pulmonary circulation provides prognostic insights into VD. Simultaneous assessment of PTT and STT enhances specificity compared to isolated PTT evaluation, predicting combined adverse events. RPT is independently associated with renal impairment.

CLINICAL RELEVANCE STATEMENT

For the first time, it is described that transit time can be evaluated in systemic circulation and in peripheral organs and that this assessment can be easily made from conventional CMR perfusion images and holds significant prognostic value.

KEY POINTS

Pulmonary transit time is a valuable hemodynamic parameter; systemic transit time may also be valuable. Transit time can be measured in the systemic circulation, and is longer in patients with ventricular dysfunction. Systemic transit time assessed by magnetic resonance imaging identifies patients with ventricular dysfunction who will experience events during follow-up.

Feasibility and Implementation of a 4D Free-Breathing Variable Density Stack-of-Stars Functional Magnetic Resonance Urography in Young Children Without Sedation

BACKGROUND

Functional magnetic resonance urography (MRU) is well established in the diagnostic workup of urinary tract anomalies in children, providing comprehensive morphological and functional information. However, dynamic contrast-enhanced images acquired in the standard Cartesian k-space manner are prone to motion artifacts. A newly introduced 4D high spatiotemporal resolution dynamic contrast-enhanced magnetic resonance imaging based on variable density elliptical centric radial stack-of-stars sharing technique has shown improved image quality regarding motions under free breathing.

OBJECTIVE

The aims of this study were to implement this 4D free-breathing sequence for functional MRU and to compare its image quality and analyzability with standard breath-hold Cartesian MRU.

MATERIALS AND METHODS

We retrospectively evaluated all functional 4D MRU performed without general anesthesia between September 2021 and December 2022 and compared them with matched pairs (age, affected kidney, diagnosis) of standard Cartesian MRU between 2016 and 2022. Image analysis was performed by 2 radiologists independently regarding the following criteria using a 4-point Likert scale, with 4 being the best: overall image quality, diagnostic confidence, respiratory motion artifacts, as well as sharpness and contrast of aorta, kidneys, and ureters. We also measured vertical kidney motion due to respiratory motion and compared the variance for each kidney using F test. Finally, both radiologists calculated the volume, split renal volume (vDRF), split renal Patlak function (pDRF), and split renal function considering the volume and Patlak function (vpDRF) for each kidney. Values were compared using Bland-Altman plots and F test.

RESULTS

Forty children (20 for 4D free-breathing and standard breath-hold, respectively) were enrolled. Ten children of each group were examined using feed-and-sleep technique (median age: 4D, 3.3 months; standard, 4.2 months), 10 were awake (median age: 4D, 8.9 years; standard, 8.6 years). Overall image quality, diagnostic confidence, respiratory motion artifacts, as well as sharpness and contrast of the aorta, kidneys, and ureters were rated significantly better for 4D free-breathing compared with standard breath-hold by both readers ( P ranging from <0.0001 to 0.005). Vertical kidney motion was significantly reduced in 4D free-breathing for the right and the left kidney (both P < 0.001). There was a significantly smaller variance concerning the differences between the 2 readers for vpDRF in 4D MRU ( P = 0.0003). In contrast, no significant difference could be demonstrated for volume ( P = 0.05), vDRF ( P = 0.93), and pDRF ( P = 0.14).

CONCLUSIONS

We demonstrated the feasibility of applying a 4D free-breathing variable density stack-of-stars imaging for functional MRU in young pediatric patients with improved image quality, fewer motion artifacts, and improved functional analyzability.

Functional MR urography in children - update 2023

BACKGROUND

Functional MR urography (fMRU) has developed into an innovative, radiation-free option for assessing parameters of kidney function in pediatric radiology. The importance of fMRU in comparison to the standardized established nuclear medicine procedure (99mTc-Mercapto-acetyltriglycerine, MAG3 scintigraphy) is shown using SWOT analysis.

METHODS

To assess the current state of research, a selective literature search was carried out in PubMed. Taking into account the current scientific status, the examination technique, preparation, and evaluation of fMRU are presented.

RESULTS

As a result of the comparison with MAG3, fMRU is suitable for certain indications and represents an optimal combination of morphological and functional representation of the kidneys and urinary tract, especially in the case of surgical consequences.

CONCLUSION

fMRU has been successfully established as a diagnostic method for assessing the morphology and function of the kidneys in competition with MAG3 scintigraphy.

KEY POINTS

· Functional MRU allows reliable statements on the morphology and function of the kidneys and urinary tract.. · The results of the functional assessment of fMRU are comparable to the results of MAG3 scintigraphy.. · The complex implementation and demanding evaluation limits the spread of fMRU as a complete alternative to MAG3 scintigraphy. fMRU is reserved for special indications.. · Functional MRU has prevailed over MAG3 scintigraphy for complex renal and urinary tract anomalies (CAKUT) that require surgical correction. An example is the clarification of dribbling in girls, which is usually based on an ectopic opening of a ureter in a double system..

CITATION FORMAT

· Kirsch H, Krüger P, John-Kroegel U et al. Functional MR urography in children - update 2023. Fortschr Röntgenstr 2023; 195: 1097 - 1105.

Magnetic Resonance Imaging in Clinical Trials of Diabetic Kidney Disease

Chronic kidney disease (CKD) associated with diabetes mellitus (DM) (known as diabetic kidney disease, DKD) is a serious and growing healthcare problem worldwide. In DM patients, DKD is generally diagnosed based on the presence of albuminuria and a reduced glomerular filtration rate. Diagnosis rarely includes an invasive kidney biopsy, although DKD has some characteristic histological features, and kidney fibrosis and nephron loss cause disease progression that eventually ends in kidney failure. Alternative sensitive and reliable non-invasive biomarkers are needed for DKD (and CKD in general) to improve timely diagnosis and aid disease monitoring without the need for a kidney biopsy. Such biomarkers may also serve as endpoints in clinical trials of new treatments. Non-invasive magnetic resonance imaging (MRI), particularly multiparametric MRI, may achieve these goals. In this article, we review emerging data on MRI techniques and their scientific, clinical, and economic value in DKD/CKD for diagnosis, assessment of disease pathogenesis and progression, and as potential biomarkers for clinical trial use that may also increase our understanding of the efficacy and mode(s) of action of potential DKD therapeutic interventions. We also consider how multi-site MRI studies are conducted and the challenges that should be addressed to increase wider application of MRI in DKD.

Functional Magnetic Resonance Urography in Children-Tips and Pitfalls

MR urography can be an alternative to other imaging methods of the urinary tract in children. However, this examination may present technical problems influencing further results. Special attention must be paid to the parameters of dynamic sequences to obtain valuable data for further functional analysis. The analysis of methodology for renal function assessment using 3T magnetic resonance in children. A retrospective analysis of MR urography studies was performed in a group of 91 patients. Particular attention was paid to the acquisition parameters of the 3D-Thrive dynamic with contrast medium administration as a basic urography sequence. The authors have evaluated images qualitatively and compared contrast-to-noise ratio (CNR), curves smoothness, and quality of baseline (evaluation signal noise ratio) in every dynamic in each patient in every protocol used in our institution. Quality analysis of the image (ICC = 0.877, p < 0.001) was improved so that we have a statistically significant difference in image quality between protocols (χ²(3) = 20.134, p < 0.001). The results obtained for SNR in the medulla and cortex show that there was a statistically significant difference in SNR in the cortex (χ²(3) = 9.060, p = 0.029). Therefore, the obtained results show that with the newer protocol, we obtain lower values of standard deviation for TTP in the aorta (in ChopfMRU: first protocol SD = 14.560 vs. fourth protocol SD = 5.599; in IntelliSpace Portal: first protocol SD = 15.241 vs. fourth protocol SD = 5.506). Magnetic resonance urography is a promising technique with a few challenges that arise and need to be overcome. New technical opportunities should be introduced for everyday practice to improve MRU results.