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Abstract
Ultrasound imaging is a key investigatory step in the evaluation of chronic kidney disease and kidney transplantation. It uses nonionizing radiation, is noninvasive, and generates real-time images, making it the ideal initial radiographic test for patients with abnormal kidney function. Ultrasound enables the assessment of both structural (form and size) and functional (perfusion and patency) aspects of kidneys, both of which are especially important as the disease progresses. Ultrasound and its derivatives have been studied for their diagnostic and prognostic significance in chronic kidney disease and kidney transplantation. Ultrasound is rapidly growing more widely accessible and is now available even in handheld formats that allow for bedside ultrasound examinations. Given the trend toward ubiquity, the current use of kidney ultrasound demands a full understanding of its breadth as it and its variants become available. We described the current applications and future directions of ultrasound imaging and its variants in the context of chronic kidney disease and transplantation in this review.
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Affiliation(s)
- Rohit K. Singla
- MD and PhD Program, University of British Columbia, Vancouver, Canada
- School of Biomedical Engineering, University of British Columbia, Vancouver, Canada
- Address for Correspondence: Rohit Singla, MASc, The University of British Columbia, 2332 Main Mall, Vancouver, BC, Canada, V6T 1Z4.
| | - Matthew Kadatz
- Department of Nephrology, University of British Columbia, Vancouver, Canada
| | - Robert Rohling
- School of Biomedical Engineering, University of British Columbia, Vancouver, Canada
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada
| | - Christopher Nguan
- Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
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Araújo NC, Suassuna JHR, Fernandes RDCL. Transcranial sonography depicts a larger substantia nigra echogenic area in renal transplant patients on calcineurin inhibitors than on rapamycin. BMC Nephrol 2022; 23:108. [PMID: 35300603 PMCID: PMC8931960 DOI: 10.1186/s12882-022-02741-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND After kidney transplantation neurologic manifestations may develop, including Parkinson's disease (PD). An enlarged substantia nigra (SN) by transcranial sonography has been recognized as a marker of PD. METHODS In renal transplant recipients (RTRs = 95) and controls (n = 20), measurement of mesencephalon, SN, third ventricle, spleen and carotid intima-media thickness (cIMT) and middle cerebral artery (MCA), kidney and spleen arteries Doppler resistive index (RI) were performed. RESULTS RTRs had larger SN, third ventricle and cIMT and higher renal RI than controls. The SN was larger in the CNIs group than in controls and rapamycin group, while the third ventricle was similar between patients but larger than in controls. In RTRs, SN showed a direct linear correlation with spleen and the third ventricle with age, cIMT and RI of the MCA, kidney and spleen. In CNIs group the SN correlated positively with age and cIMT, while the third ventricle reproduced RTRs correlations. Rapamycin group showed a direct linear relationship between the third ventricle and age and RI of the MCA, kidney and spleen; SN showed no correlations. CONCLUSION RTRs on CNIs present a larger SN area than on rapamycin, probably due to the antiproliferative effect of rapamycin. This finding might be relevant when interpreting TCS in RTRs.
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Affiliation(s)
- Nordeval Cavalcante Araújo
- Division of Nephrology, University of the State of Rio de Janeiro, Boulevard 28 de Setembro, 77 - Vila Isabel, Rio de Janeiro-RJ, 20551-030, Brazil.
| | - José Hermógenes Rocco Suassuna
- Division of Nephrology, University of the State of Rio de Janeiro, Boulevard 28 de Setembro, 77 - Vila Isabel, Rio de Janeiro-RJ, 20551-030, Brazil
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Wong-You-Cheong JJ, Nikolaidis P, Khatri G, Dogra VS, Ganeshan D, Goldfarb S, Gore JL, Gupta RT, Heilbrun ME, Lyshchik A, Metter DF, Purysko AS, Savage SJ, Smith AD, Wang ZJ, Wolfman DJ, Lockhart ME. ACR Appropriateness Criteria® Renal Failure. J Am Coll Radiol 2021; 18:S174-S188. [PMID: 33958111 DOI: 10.1016/j.jacr.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 11/16/2022]
Abstract
Renal failure can be divided into acute kidney injury and chronic kidney disease. Both are common and result in increased patient morbidity and mortality. The etiology is multifactorial and differentiation of acute kidney injury from chronic kidney disease includes clinical evaluation, laboratory tests, and imaging. The main role of imaging is to detect treatable causes of renal failure such as ureteral obstruction or renovascular disease and to evaluate renal size and morphology. Ultrasound is the modality of choice for initial imaging, with duplex Doppler reserved for suspected renal artery stenosis or thrombosis. CT and MRI may be appropriate, particularly for urinary tract obstruction. However, the use of iodinated and gadolinium-based contrast should be evaluated critically depending on specific patient factors and cost-benefit ratio. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Jade J Wong-You-Cheong
- University of Maryland School of Medicine, Baltimore, Maryland, Vice Chair, Quality and Safety, Diagnostic Radiology, University of Maryland Medical Center.
| | | | - Gaurav Khatri
- Panel Vice-Chair, UT Southwestern Medical Center, Dallas, Texas
| | - Vikram S Dogra
- University of Rochester Medical Center, Rochester, New York
| | | | - Stanley Goldfarb
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, American Society of Nephrology
| | - John L Gore
- University of Washington, Seattle, Washington, American Urological Association
| | - Rajan T Gupta
- Duke University Medical Center, Durham, North Carolina, Chair, Meetings Sub-Committee, ACR, Member, Commission on Publications and Lifelong Learning
| | | | - Andrej Lyshchik
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, Deputy Editor, Journal of Ultrasound in Medicine
| | - Darlene F Metter
- UT Health San Antonio, San Antonio, Texas, Past-President and Alternate Councilor, Texas Radiological Society, Chair, IT Health San Antonio Radioactive Drug and Research Committee, Chair, Nuclear Regulatory Commission Advisory Committee on the Medical Uses of Isotopes, Vice-Speaker, Society of Nuclear Medicine and Molecular Imaging House of Delegates, Member, Texas Department of State Health Services Texas Radiation Advisory Board
| | | | - Stephen J Savage
- Medical University of South Carolina, Charleston, South Carolina, American Urological Association
| | - Andrew D Smith
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Zhen J Wang
- University of California San Francisco School of Medicine, San Francisco, California
| | - Darcy J Wolfman
- Johns Hopkins University School of Medicine, Washington, District of Columbia
| | - Mark E Lockhart
- Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama, Chair, ACR Appropriateness Committee
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Anile A, Ferrario S, Campanello L, Orban MA, Castiglione G. Renal resistive index: a new reversible tool for the early diagnosis and evaluation of organ perfusion in critically ill patients: a case report. Ultrasound J 2019; 11:23. [PMID: 31598787 PMCID: PMC6785600 DOI: 10.1186/s13089-019-0138-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 09/06/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND We reported a case of early detection of peripheral hypoperfusion trough the evaluation of a new index in intensive care: Renal Doppler Resistive Index (RRI). CASE PRESENTATION We admitted a 76-year-old man who underwent ileostomy and hernioplasty because of an intestinal occlusion due to obstructive strangulated right inguinal hernia. The post-operative period was characterised by hemodynamic instability and he needed an invasive hemodynamic monitoring, administration of vasopressors and continuous renal replacement therapy (CRRT). Then, hemodynamic stability was obtained and vasopressors interrupted. RRI was lower than 0.7. In the eleventh post-operative day, despite stable macrocirculatory parameters, we found increased values of RRI. An abdomen ultrasound first and then a CT scan revealed the presence of bleeding from the previous ileostomy. Hence, the patient immediately underwent another surgical operation. CONCLUSIONS RRI modification appears to be more precocious than any other hemodynamic, microcirculatory and metabolic parameter routinely used. RRI has been widely used to assess renal function in critically ill patients; now, we presume that RRI could represent a common and useful tool to manage target therapy in critical condition.
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Affiliation(s)
- Antonio Anile
- Intensive Care Unit, Ospedale Vittorio Emanuele, AOU Policlinico–Vittorio Emanuele, Catania, Italy
| | - Silvia Ferrario
- Section of Nephrology, Department of Clinical and Experimental Medicine, Policlinico Universitario, University of Catania, Catania, Italy
| | - Lorena Campanello
- School of Anaesthesia and Intensive Care, University Hospital “G. Rodolico”, University of Catania, Catania, Italy
| | - Maria Antonietta Orban
- School of Anaesthesia and Intensive Care, University Hospital “G. Rodolico”, University of Catania, Catania, Italy
| | - Giacomo Castiglione
- Intensive Care Unit, Ospedale Vittorio Emanuele, AOU Policlinico–Vittorio Emanuele, Catania, Italy
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Cavalcante Araújo N. Does the measurement of the difference of resistive indexes in spleen and kidney might be used for characterization of intrarenal tardus parvus phenomenon in chronic kidney disease? Med Hypotheses 2019; 124:1-6. [PMID: 30798900 DOI: 10.1016/j.mehy.2019.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/10/2019] [Accepted: 01/23/2019] [Indexed: 01/20/2023]
Abstract
Doppler sonography is used as a routine test for detection of renal artery stenosis (RAS). Although increased peak systolic velocity at the site of the narrowing is a widely accepted method for assessing main renal artery stenosis, tardus parvus phenomenon detected on the downstream blood flow has been used as an alternative to direct insonation of the main artery. However, the uncertainty about the best Doppler parameter to be used for characterization of tardus parvus has yielded a variety of studies. Recently, the difference between the resistive index of the spleen and kidney (RISK) has been proposed as a potential marker of kidney damage and Doppler criterion for RAS in hypertensive patients without chronic kidney disease (CKD). The hypothesis of this study was to speculate further and propose the RISK as valuable new Doppler diagnostic criteria for the tardus parvus in CKD too. Data from 183 control patients and 135 chronic kidney disease patients (CKD) were included in the study to test the feasibility of the method and plausibility of the hypothesis. Criteria inclusion was a color Doppler ultrasound measurement of the renal (RRI) and spleen resistive index (SRI). Serum creatinine (0.83 ± 0.20 vs 3.27 ± 1.74), RRI (0.60 ± 0.06 vs 0.69 ± 0.09), SRI (0.55 ± 0.06 vs 0.58 ± 0.09), RISK (0.06 ± 0.04 vs 0.11 ± 0.08), and spleen size (94.1 ± 13.2 vs 100.8 ± 16.5) were higher in CKD patients (p < 0.05). RRI correlated with SRI in both groups; however, the coefficient of determination was different (Z = 2.29, p = 0.022). In the CKD group, RISK correlated inversely with age (r = -0.276; p = 0.001) and positively with creatinine (r = 0.509; p < 0.001). In the multivariate analysis, creatinine remained an independent predictor of the high RISK (Wald = 13.07; p < 0.001; odds ratio = 1.87; 95% confidence interval 1.33-2.62). Since extraneous factors similarly influence RRI and SRI, the SRI can be considered the correction factor that can estimate the cardiovascular burden on the RRI. Consequently, according to the suggested hypothesis, RISK helps to distinguish the tardus parvus related to RAS from tardus parvus related to systemic influences on Doppler morphology. The identification of the underlying mechanisms of tardus parvus, would help a more accurate characterization of the phenomenon and improve screening and diagnostic test for RAS in CKD patients.
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Di Nicolò P, Granata A. Renal intraparenchymal resistive index: the ultrasonographic answer to many clinical questions. J Nephrol 2018; 32:527-538. [PMID: 30539416 DOI: 10.1007/s40620-018-00567-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 11/22/2018] [Indexed: 02/06/2023]
Abstract
The use of renal resistive indices (RRIs) for the study of renal microcirculation has in the past been proposed for the identification of renal organ damage or even to specifically identify injury to some areas of the renal parenchyma. Nevertheless, according to the most recent evidences from literature this organ-based conception of RRIs has been proven to be partial and unable to explain the RRIs variations in clinical settings of sepsis or combined organ failure of primitively extrarenal origin or, more generally, the deep connection between RRIs and hemodynamic factors such as compliance and pulsatility of the large vessels. The aim of this review is to explain the physiopathological basis of RRIs determination and the most common interpretative errors in their analysis. Moreover, through a comprehensive vision of these Doppler indices, the traditional and emerging clinical application fields for RRIs are discussed.
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Affiliation(s)
- Pierpaolo Di Nicolò
- Nephrology and Dialysis Unit, "S. Maria della Scaletta" Hospital, Via Montericco n. 4, 40026, Imola, BO, Italy.
| | - Antonio Granata
- Nephrology and Dialysis Unit, "S. Giovanni di Dio" Hospital, Agrigento, Italy
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Gray Scale Ultrasound, Color Doppler Ultrasound, and Contrast-Enhanced Ultrasound in Renal Parenchymal Diseases. Ultrasound Q 2018; 34:250-267. [DOI: 10.1097/ruq.0000000000000383] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Beaubien-Souligny W, Denault A, Robillard P, Desjardins G. The Role of Point-of-Care Ultrasound Monitoring in Cardiac Surgical Patients With Acute Kidney Injury. J Cardiothorac Vasc Anesth 2018; 33:2781-2796. [PMID: 30573306 DOI: 10.1053/j.jvca.2018.11.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Indexed: 12/15/2022]
Abstract
The approach to the patient with acute kidney injury (AKI) after cardiac surgery involves multiple aspects. These include the rapid recognition of reversible causes, the accurate identification of patients who will progress to severe stages of AKI, and the subsequent management of complications resulting from severe renal dysfunction. Unfortunately, the inherent limitations of physical examination and laboratory parameter results are often responsible for suboptimal clinical management. In this review article, the authors explore how point-of-care ultrasound, including renal and extrarenal ultrasound, can be used to complement all aspects of the care of cardiac surgery patients with AKI, from the initial approach of early AKI to fluid balance management during renal replacement therapy. The current evidence is reviewed, including knowledge gaps and future areas of research.
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Affiliation(s)
- William Beaubien-Souligny
- Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Anesthesiology, Montreal Heart Institute, Montréal, Canada.
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Montréal, Canada; Division of Intensive Care, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Pierre Robillard
- Department of Radiology, Montreal Heart Institute, Montréal, Canada
| | - Georges Desjardins
- Department of Anesthesiology, Montreal Heart Institute, Montréal, Canada
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Grupp C, Koziolek MJ, Wallbach M, Hoxhold K, Müller GA, Bramlage C. Difference between renal and splenic resistive index as a novel criterion in Doppler evaluation of renal artery stenosis. J Clin Hypertens (Greenwich) 2018; 20:582-588. [PMID: 29450973 DOI: 10.1111/jch.13212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 10/31/2017] [Accepted: 11/07/2017] [Indexed: 12/28/2022]
Abstract
Detection of renal artery stenosis (RAS) using Doppler is difficult to evaluate, particularly under conditions such as bilateral RAS or difficultly accessible renal arteries (RA). The objective of the present study was to assess the utility of splenic arterial compared to renal flow as an additional parameter in the Doppler evaluation of RAS. The difference between the resistive indices (RI) determined in renal and splenic parenchymal arteries (ΔRIK-S ) was evaluated in 181 hypertensive subjects without any evidence of RAS. Subsequently 47 RA in 24 patients with suspected RAS were angiographically assessed. A ΔRIK-S of 0.055 (median) was determined in the population without any evidence of RAS similar to RA with angiographically excluded stenosis (ΔRIK-S 0.068). In contrast, in angiographic proven RAS, ΔRIK-S was significantly lower (-0.050; P < .005). The assessment of the ΔRIK-S , proved to be an easily feasible parameter, which improves the diagnostic accuracy in the detection of RAS.
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Affiliation(s)
- Clemens Grupp
- Department of Nephrology & Rheumatology, Georg-August-University Göttingen, Göttingen, Germany
| | - Michael J Koziolek
- Department of Nephrology & Rheumatology, Georg-August-University Göttingen, Göttingen, Germany
| | - Manuel Wallbach
- Department of Nephrology & Rheumatology, Georg-August-University Göttingen, Göttingen, Germany
| | - Kerstin Hoxhold
- Department of Nephrology & Rheumatology, Georg-August-University Göttingen, Göttingen, Germany
| | - Gerhard A Müller
- Department of Nephrology & Rheumatology, Georg-August-University Göttingen, Göttingen, Germany
| | - Carsten Bramlage
- Department of Nephrology & Rheumatology, Georg-August-University Göttingen, Göttingen, Germany
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Symmetric dimethylarginine (SDMA) outperforms asymmetric dimethylarginine (ADMA) and other methylarginines as predictor of renal and cardiovascular outcome in non-dialysis chronic kidney disease. Clin Res Cardiol 2017; 107:201-213. [DOI: 10.1007/s00392-017-1172-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 10/20/2017] [Indexed: 10/18/2022]
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Renal Resistive Index: not only kidney. Clin Exp Nephrol 2016; 21:359-366. [DOI: 10.1007/s10157-016-1323-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 08/11/2016] [Indexed: 12/11/2022]
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Lennartz CS, Pickering JW, Seiler-Mußler S, Bauer L, Untersteller K, Emrich IE, Zawada AM, Radermacher J, Tangri N, Fliser D, Heine GH. External Validation of the Kidney Failure Risk Equation and Re-Calibration with Addition of Ultrasound Parameters. Clin J Am Soc Nephrol 2016; 11:609-15. [PMID: 26787778 DOI: 10.2215/cjn.08110715] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 12/14/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Progression of CKD toward ESRD is heterogeneous. The Kidney Failure Risk Equation (KFRE) was developed to identify CKD patients at high risk of ESRD. We aimed to externally validate KFRE and to test whether the addition of predefined Duplex ultrasound markers - renal resistive index (RRI) or difference of resistive indices in spleen and kidney (DI-RISK) - improved ESRD prediction. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The prospective Cardiovascular and Renal Outcome in CKD 2-4 Patients-The Fourth Homburg evaluation (CARE FOR HOMe) study recruits CKD stage G2-G4 patients referred to a tertiary referral center for nephrologic care. Four hundred three CARE FOR HOMe participants enrolled between 2008 and 2012 had available RRI measurements at study inclusion; they were subsequently followed for a mean of 4.4±1.6 years. This subcohort was used to validate KFRE and to assess the added value of the ultrasound markers (new models KFRE+RRI and KFRE+DI-RISK). Model performance was assessed by log-likelihood ratio test, c-statistic, integrated discrimination improvement metrics (for study participants without subsequent ESRD [IDI No ESRD] and for patients with ESRD [IDI ESRD]), and calibration plots. If either new model improved on KFRE, we determined to validate it in an independent cohort of 162 CKD patients. RESULTS KFRE predicted ESRD in CARE FOR HOMe participants with a c-statistic of 0.91 (95% confidence interval, 0.83 to 0.99). Adding RRI improved the KFRE model (P<0.001), and the KFRE+RRI model was well calibrated; however, the c-statistic (0.91 [0.83-1.00]) was similar, and overall sensitivity (IDI No ESRD=0.05 [0.00-0.10]) or overall specificity (IDI ESRD=0.00 [0.00-0.01]) did not improve. Adding DI-RISK did not improve the KRFE model. In the external validation cohort, we confirmed that the KFRE+RRI model did not outperform KFRE. CONCLUSIONS Routine Duplex examinations among CKD patients did not improve risk prediction for progression to ESRD beyond a validated equation.
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Affiliation(s)
- Claudia S Lennartz
- Department of Nephrology and Hypertension, Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - John William Pickering
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand; Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Sarah Seiler-Mußler
- Department of Nephrology and Hypertension, Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Lucie Bauer
- Department of Nephrology and Hypertension, Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Kathrin Untersteller
- Department of Nephrology and Hypertension, Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Insa E Emrich
- Department of Nephrology and Hypertension, Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Adam M Zawada
- Department of Nephrology and Hypertension, Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Jörg Radermacher
- Department of Nephrology and Hypertension, Johannes Wesling Klinikum, Minden, Germany; and
| | - Navdeep Tangri
- Department of Medicine and Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Danilo Fliser
- Department of Nephrology and Hypertension, Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Gunnar H Heine
- Department of Nephrology and Hypertension, Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany;
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Duplex scanning has a limited role in the evaluation of patients with renal failure. J Vasc Surg 2014; 60:1593-8. [PMID: 25312535 DOI: 10.1016/j.jvs.2014.08.109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 08/26/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Although common indications for renal duplex scanning (RDS) include hypertension (HT) and renal failure (RF), the role of RDS in the evaluation of patients with RF is not known. The goal of this study was to define ultrasound findings with predictive or discriminatory value in patients with RF and to identify patients undergoing a renal artery intervention as a result of RDS findings. METHODS We conducted a retrospective review of 214 consecutive patients referred to an Intersocietal Accreditation Commission-accredited vascular laboratory for an initial RDS from January 1, 2010, to June 30, 2010. RDS included direct ultrasound evaluation of the main renal vessels and renal parenchyma. Significant renal artery stenosis of ≥ 60% diameter reduction was indicated by a renal/aortic velocity ratio ≥ 3.5 and abnormally increased parenchymal resistance by an end-diastolic ratio ≤ 0.3. RESULTS We separated the patients into two groups by indication for RDS: Group I (HT alone, n = 102) and group II (RF alone or with HT, n = 112). When group I was compared with group II, there were significant differences in gender (50% vs 67% male; P = .013), age (50.9 ± 18.5 vs 60.0 ± 14.8 years; P < .001), mean arterial pressure (103.1 ± 18.8 vs 85.7 ± 17.0 mm Hg; P < .001), and creatinine (0.95 ± 0.35 vs 2.25 ± 1.07 mg/dL; P < .001). In group I patients, 86 (84.3%) had normal parenchymal resistance, whereas in group II patients, 68 (60.7%) had abnormally increased parenchymal resistance unilaterally or bilaterally (P < .001). Unilateral or bilateral renal artery stenosis was identified in six group I patients and in three group II patients (P = .315). Evaluation of group II patients revealed a diagnosis of decompensated congestive heart failure (CHF) and the presence of unilateral or bilateral increased parenchymal resistance in 27 of 68 (39.7%) vs nine of 44 (20.4%) with CHF and normal parenchymal resistance. One renal artery angioplasty was performed in a patient with unilateral renal artery stenosis and fibromuscular dysplasia. CONCLUSIONS Renal artery stenosis is extremely uncommon in patients undergoing RDS for RF, indicating that ischemic nephropathy is rarely a cause of RF in these patients. Abnormally increased renal parenchymal resistance is frequently found in patients being evaluated for RF and is associated with increasing creatinine and age. A diagnosis of CHF is also more common in patients with increased parenchymal resistance. Although patients who undergo RDS for RF rarely require renal artery interventions, ultrasound indices of parenchymal resistance may serve as a marker for renal disease and cardiovascular morbidity. Further studies are required to determine the prognostic significance of these ultrasound findings in the setting of RF.
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Affiliation(s)
- W Charles O'Neill
- From the Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA.
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Rogacev KS, Pickering JW, Seiler S, Zawada AM, Emrich I, Fliser D, Heine GH. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation incorporating both cystatin C and creatinine best predicts individual risk: a cohort study in 444 patients with chronic kidney disease. Nephrol Dial Transplant 2013; 29:348-55. [PMID: 24166454 DOI: 10.1093/ndt/gft422] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The recently introduced CKD-EPIcreat-cys equation surpassed creatinine-based equations for GFR estimation in a large cross-sectional analysis. However, its performance to predict individual risk of CKD progression and death in patients with various underlying CKD etiologies is unknown. METHODS We recruited 444 patients with CKD GFR categories 2-4 (eGFR 15-89 mL/min/1.73 m2); baseline eGFR was estimated by the established MDRD and CKD-EPIcreat equations and by the novel CKD-EPIcreat-cys equation. RESULTS Patients were followed for 2.7±1.2 years for the occurrence of the combined predefined endpoint event: death, need for renal replacement therapy or halving of eGFR. The endpoint occurred in 62 patients. Reclassification from MDRD determined categories to CKD-EPIcreat-cys categories yielded net reclassification improvements for those with the endpoint event (NRIevents) of 27.4% (95% CI: 16.7-40.0%) and for those without the event (NRInon-events) of -3.1% (-8.2 to 1.6%). Similarly, reclassification from CKD-EPIcreat categories to CKD-EPIcreat-cys categories yielded an NRIevents of 22.6% (10.2-34.3%) and NRInon-events of -11.3% (-15.9 to -6.5%). Addition of albuminuria to each eGFR equation increased the calculated risk of the outcome for a net 26-32% of those who subsequently reached the endpoint, and reduced the calculated risk in a net 21-23% in non-event patients, but only minimally. CONCLUSIONS The CKD-EPIcreat-cys equation assigned patients who went on to have the event to more appropriate CKD risk categories than MDRD and CKD-EPIcreat, but patients without the event to less appropriate categories than CKD-EPIcreat. Addition of albuminuria marginally improved risk classification for those who had the event.
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Affiliation(s)
- Kyrill S Rogacev
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Centre, Homburg, Germany
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