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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2006  |  Volume : 17  |  Issue : 4  |  Page : 540-548
The Place of Ultrasound in Renal Medicine

School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

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Today, ultrasound is one of the most commonly used diagnostic tools, the reasons being that it is non-invasive, reliable, widely available, and affordable. In this paper, we review the place of ultrasound in the diagnosis and follow-up of patients with kidney diseases. We briefly discuss a wide range of kidney diseases for which ultrasound imaging is still performed as one of the initial steps of diagnosis. To achieve this, five following categories are addressed: congenital anomalies of the kidney; renal cystic diseases; renal infections; kidney stones; and kidney tumors. The sonographic findings of these diseases are discussed.

Keywords: Ultrasound, Congenital anomaly, Renal cystic disease, Renal infection, Kidney stones, Kidney tumors.

How to cite this article:
Gheissari A. The Place of Ultrasound in Renal Medicine. Saudi J Kidney Dis Transpl 2006;17:540-8

How to cite this URL:
Gheissari A. The Place of Ultrasound in Renal Medicine. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2023 Jan 30];17:540-8. Available from: https://www.sjkdt.org/text.asp?2006/17/4/540/32493

   Introduction Top

Medicine has always had a strong affiliation to physics. In the last century, various diagnostic tools, which are based on different phenomena in physics, have been incorporated into medi­cine. They include sound waves, laser waves, magnetic devices, optical instruments, etc. Among them, ultrasound has been used in clinical applications for the last forty years.[1] The diagnostic capability of ultrasound images is based on the well-known observation that, when sound waves are sent to different organs and structures, those that reflect sound waves back to the transducer (such as the liver) seem white or echogenic. Conversely, the structures that do not reflect back sound waves (such as fluids) appear black or anechoic. In addition, soft tissues appear as grey images. [1]

Although more advanced diagnostic tools have been recently incorporated along with the ultrasound images, conventional sonography is still one of the most common imaging methods used in the diagnosis and follow-up of patients with kidney diseases. Ultrasound is a non-invasive, reliable, widely available, and affordable diagnostic tool. In some cases, ultrasound plays a major role in early detection and also in applying proper management. How­ever, it should be mentioned that ultrasound is neither complete (perfect) nor fully discri­minative in diagnosing renal diseases.

In this paper, we review the role of ultrasound in diagnosing renal disease. To achieve this, we first briefly discuss the anatomy of the kidney. Then, we suggest the following taxo­nomy for the most important kidney diseases:

a) Congenital anomalies of the kidney

b) Renal cystic diseases

c) Renal infections

d) Kidney stones and nephrocalcinosis

e) Tumors of the kidney

Each of the above five groups is further discussed by addressing its main entities, followed by the sonographic findings of the discussed disease.

   Anatomy of the Kidney Top

The kidneys are located in a retroperito­neal position on either side of the vertebral column and against the psoas muscles. In a normal adult, each kidney is about 11 centi­metres in length and 150 gm in weight. Renal length in childhood depends on the age, gender, race, weight, and height of the child. Accord­ingly, a renal length normogram based on the ultrasound measurement in pediatric patients may be used to assess kidney size [2]. The right kidney usually is smaller than the left, and also lies one to two centimetres lower than the left kidney. [3]

   Congenital Anomalies of the Kidney Top

Renal Hypoplasia

Renal hypoplasia is a histologic term that refers to a morphologically normal kidney, except for its small size due to either a reduced number and/or size of nephrons.[4],[5],[6],[7] Hypoplastic kidneys do not contain undiffer­entiated tissues. Although true hypoplasia is an uncommon anomaly, unilateral hypoplasia is not rare. Most patients with unilateral hypoplasia remain asymptomatic. However, they are more prone to developing hypertension in comparison with the normal population.[8]

In sonography images, an involved kidney is smaller than normal, with fairly smooth outline and borders. In addition, it typically contains five or less calyces. [5],[6]

Renal Agenesis

Agenesis is the result of failure of the ureteric bud to reach to metanephros stage. [5],[6],[7] Bilateral renal agenesis or absence of both kidneys is not compatible with life. In unilateral renal agenesis, sonography shows absence of the ipsilateral kidney and some degree of hyper­trophy of the contralateral kidney. The adrenal gland of the involved kidney may or may not be absent. [9]

Renal Ectopia

Kidney ectopia is the result of failure of the normal ascent of the kidney to the level of the second lumbar vertebra during embryo­genesis. Various anomalies associated with renal ectopia have been reported. The most common one, which occurs in 20 to 70% of all types of ectopic kidneys, is vesicoureteral reflux (VUR). The other reported anomalies include contralateral renal dysplasia, crypt­orchidism, hypospadias, renal cell carcinoma, and, in rare cases, abdominal aortic aneu­rysm. [10],[11],[12] On ultrasound, ectopic kidneys are often small in size, abnormally rotated, hyper echoic, and have some degrees of decreased function and also pelvicalyceal dilatation. [5],[6]

Duplex Collecting System

A duplex collecting system is the most common congenital anomaly of the urinary tract. Duplication may be complete or in­complete. A complete duplex collecting system is composed of two separate collecting systems and two separate ureters with distinct orifices. In the incomplete form, the ureters join so that they have a single common ureteral orifice.[5]

An increased incidence of ureteropelvic junction obstruction is reported with duplex collecting systems. [9],[13] In complete dupli­cation, the ureter that drains the lower pole is more susceptible to VUR, and the ectopic ureter from the upper pole is prone to obstru­ction, reflux, or both. [5],[6] On sonography, the duplication is seen as two central echogenic renal sinuses. Hydronephrosis of the upper pole and two separate collecting systems (if seen) is diagnostic. Furthermore, ureterocele may be seen. [5]

Ureteropelvic Junction Obstruction

Ureteropelvic junction obstruction (UPJO) is one of the most frequent congenital ano­malies of the urinary tract. UPJO may be caused by both intrinsic and extrinsic com­pressive factors. [14] These different factors cause bilateral obstruction in 10 to 30% of cases. [15] If unilateral obstruction occurs, the left kidney is affected twice as frequently as the right one. [5] Ultrasound shows different degrees of dilatation of the renal pelvis and communicating calyces without a dilated ureter. Increased parenchymal echogenicity, cortical thinning, and cortical cysts are also reported. [5],[14],[16]

   Renal Cystic Disease Top

Simple Renal Cysts

A cyst is a cavity lined by epithelium and filled with liquid or semisolid material. Cystic lesions of the kidney are divided into different groups: simple cyst, parapelvic and peripelvic cysts, complex renal cysts, and acquired cystic disease of dialysis.[5],[6]Simple cysts are more common than the others. Although advanced age is reported to increase the incidence of simple cysts, the definite pathogenesis of simple renal cysts is not yet completely understood. Most simple renal cysts are symptom free. [5] Simple cysts with the following specifications in the ultrasound images can be considered benign:

a) Echogenic, or echo-free masses with distal acoustic enhancement [5],[6]

b) Cysts having sharp borders and round or oval shapes [5],[6]

c) Occasionally, presence of one or two fine internal septae [6]

It should be emphasized that thick and dense areas of calcification with thickened septae, irregular outlines, or solid areas of enhance­ment in the cyst will increase the likelihood that there are malignant lesions. [17],[18],[19]

Medullary Sponge Kidney

Medullary sponge kidney is a congenital cystic disease of unknown etiology consisting of fusiform or cystic dilatation of medullary collecting ducts. [8],[20] The disease is generally bilateral, although in rare cases it may be unilateral or segmental. [6] Although the disease has a benign and non-progressive course, the increased incidence of nephrocalcinosis and UTI is troublesome. Mild defects of renal acidification, urinary concentration, and renal calcium handling are also reported. [5],[8],[20],[21] In sonography images, hyperechogenicity of the medulla due to nephrocalcinosis is the most common feature. Sometimes, large sized medullary cysts are visible. [6]

Medullary Cystic Disease

The juvenile nephronophthisis-medullary cystic disease (JN-MCD) is a complex of progressive heterogeneous tubulointerstitial nephritis of autosomal inheritance. [8],[22],[23]

Because of the application of advanced imaging and diagnostic methods, the disease is being reported more than before.[22] The time of presentation of clinical manifestations varies among different age-groups. The most common signs and symptoms include polyuria, poly­dypsia, secondary enuresis, anemia, and end-stage renal disease (ESRD). Renal cysts may not be seen in all patients. [23]

Ultrasound is one of the best techniques for diagnosis and screening families with a positive history of JN-MCD in their first­degree relatives.[24] In sonography images, renal hyperechogenicity and loss of cortico­medullary differentiation are the most common abnormal findings. Corticomedullary and medullary renal cysts and small sized kidneys might appear in later stages of life. [8],[24]

Polycystic Kidney Disease

Polycystic kidney disease, one of the most common hereditary progressive kidney diseases, is divided into two major groups: autosomal dominant (ADPKD) and autosomal recessive (ARPKD). ADPKD is one of the most common hereditary diseases. [25],[26] Multiple renal cysts and progressive renal enlargement are the main features of ADPKD, usually appearing after the third decade. [26],[27] However, the spectrum of presentation of signs and symptoms varies among patients. Both renal and extra-renal manifestations are reported. [27] Among the extra-renal manifestations, liver, pancreatic and splenic cysts, as well as cardiovascular anomalies and Berry aneurisms of the brain are more common. [6],[27]

Ultrasound is suggested as the preferred method for screening families with a posi­tive history of ADPKD in their first-degree relatives. [5] Sonography images may show different views, from hyper echogenic large kidneys in the prenatal period to normal sized kidneys with variable numbers and sizes of cysts in young adults. These cysts are round and echo-free with clear outlines and thin walls. Sometimes, hemorrhage, infection, and calcification of the cysts occur. [6],[25] The cyst-free parenchyma shows normal echo­genicity. [25]

In autosomal recessive polycystic kidney disease (ARPKD), the age of onset of clinical manifestations is variable from the perinatal period to childhood. [5] Neonates show palpable abdominal masses and respiratory failure. Hypertension, recurrent urinary tract infection (UTI), and symptoms of insidious renal failure are more common in young children, while patients who live until adolescence show hepatic fibrosis.

In ultrasound images, the kidneys are large and echogenic with decreased corticomedullary differentiation. Using high-resolution ultra­sound probes, small medullary and cortical cysts 1-8 millimetres in size may be seen. [5],[6],[16],[25],[27]

   Renal Infections Top

Acute Pyelonephritis

Acute pyelonephritis is a bacterial in­flammation of the tubulointerstitium of the kidney. [5],[28] Urinary tract infection is one of the most common infections both in children and adults, especially in female patients. [28] Vesicoureteral reflux predisposes infants and children to UTI, [29] although in adults, reflux is not a common finding. [28] Sonography is a useful method for assessment of size and echogenicity, as well as serial growth moni­toring of the kidney. [29] However, it is neither sensitive nor specific for diagnosing and/or evaluating the degree of VUR in children. [30]

From a sonographic view point, Talner et al. proposed that the term 'acute pyelonephritis' be used to refer to all cases of renal parenchymal involvement due to infections, except renal abscess. [31] According to them, the extent of the involvement could be described by one or more of the following descriptions: uni­lateral or bilateral; focal or diffuse; focal swelling or not; renal enlargement or not. At ultrasound, most frequently, there is no specific sign. [5] However, the following abnormalities are reported:

a) enlargement of the involved kidney,

b) compression of calyces and renal sinuses,

c) loss of corticomedullary differentiation,

d) echogenic, poorly marinated mass,

e) gas within the renal parenchyma [5],[6],[31],[32],[33],[34]

Alkaline-Encrusted Pyelitis

Alkaline-encrusted pyelitis is an uncommon chronic infection that involves transplanted kidneys and also native kidneys of immuno­compromised patients. The disease is chara­cterized by mucosal inflammation accompanied by deposits of ammonium magnesium phos­phate on the urothelium. [35],[36] Magnesium ammonium phosphate deposition causes calcified encrustation and stone formation in the wall of the kidney. While many urea­splitting bacteria have been demonstrated to be present in this infection,  Corynebacterium urealyticum Scientific Name Search s the most commonly reported causative pathogen. [36],[37] In ultrasound images, as one may expect, the main feature is a thickened calcification of the urothelial walls.

Renal Abscess

Untreated and partially treated pyelonephritis may lead to abscess formation. Immuno­compromised, debilitated patients and those who have diabetes or obstructive uropathies are more susceptible to abscess formation. [32],[38] Renal abscesses should be differentiated from parasitic cysts (like hydatid cysts), cystic neoplasms, and infections or hemorrhage in cysts. [5],[6] Sonography shows renal abscesses as hypo echoic heterogeneous masses with definite thick borders and, sometimes, internal septation. [5],[6]

Xanthogranulomatous Pyelonephritis

Xanthogranulomatous pyelonephritis (XGP) is a kind of chronic kidney disease that occurs when lipid laden histiocytes replace normal renal parenchyma and result in paren­chymal destruction. [5],[6] The pathogenesis of XGP is poorly understood. However, patients with a history of recurrent UTIs complicated with renal calculi, obstructive uropathy, and diabetes are more prone to XGP. [39],[40]

While no specific sonographic feature is suggested, the following findings are reported:

a) loss of corticomedullary differentiation,

b) hypo echoic masses,

c) parenchymal thinning,

d) hydronephrosis,

e) cystic areas containing debris,

f) calculi and perinephric fluid collection. [5],[6],[39],[41],[42]


The kidney is one of the common sites of post primary spread of tuberculosis. The genito­urinary tract is affected in approximately 30% of cases. [43],[44] Urinary tract tuberculosis needs 5 to 10 years to develop after primary pulmo­nary infection. [45] Both kidneys are seeded initially (hematogenous seeding), while mani­festations are usually unilateral.

Although hydrocalyces, hydronephrosis with or without debris, loss of corticomedullary differentiation, cortical thinning, and calcifi­cation are seen on sonography, echogenic or hypo echoic focal lesions with an echogenic rim are reported as the most common findings. [6],[46] It should be mentioned that excretory or retrograde urography are the preferred methods for detecting the findings of renal tuberculosis early. [43],[44]

   Kidney Stones and Nephrocalcinosis Top

Up to five percent of the population expe­riences kidney stones during their lives. [47] Increasing age and observation time will augment the recurrence rate. [48],[49],[50] Although increased incidence of kidney stones is associated with race and geographic area, many other factors are reported to increase the risk of stone formation.[47],[51] Among them, the more common ones include: family history of renal stones, over-consumption of animal protein, salty diet, obesity, obstructive uro­pathies, VUR, and some drugs such as decon­gestants, diuretics, a protease inhibitor (indinavir), and ceftriaxone.[47],[50],[52],[53]

The most common type of urinary stones consists of calcium oxalate alone or in com­bination with phosphate, seen in 60 to 80% of cases. [47],[50] The majority of stones will lodge at the ureterovesical junction, the site in the ureter with the smallest diameter. [47] Ultrasound is a common non-invasive tool for the diagnosis of kidney stones. [54] However, renal calculi may be mistaken for intrarenal vessels, calcified tumours or papillae, intrarenal gas, blood clots, and renal sinus fat. [5],[54]

Sonography is reported to demonstrate kidney stones greater than five millimetres in diameter with 100% sensitivity. [55] However, the sensitivity and specificity of ultrasound in the diagnosis of renal stones in patients with obstructive renal failure are 81 and 100% respectively. [56] On sonography, pelvicalyceal calculi are seen as echogenic foci with dense distal acoustic shadow. [6] Nephrocalcinosis is a condition in which calcification is limited to the renal parenchyma.[5] Dystrophic calci­fication usually is a result of a major vascular insult of the cortex due to space occupying lesions or severe hypovolemia. Rarely, glome­rulonephritis, hyperoxaluria, extrarenal synthesis of 1, 25 hydroxyvitamin D, and Alport's syn­drome may cause dystrophic calcification.[57],[58] On sonography, dystrophic calcification may be seen as a thin rim at the margin of the cortex, resembling railroad tracks.[58] How­ever, metastatic nephrocalcinosis is the result of hypercalcemic states. In this latter situation, the location of calcium deposits may be cortical or medullary. Hyperparathyroidism, renal tubular acidosis, and medullary sponge kidney are some of the most common causes of medullary nephrocalcinosis.[5],[58],[59]

In ultrasound images, cortical and medullary nephrocalcinosis are shown by hyperecho­genicity of the cortex and medulla, respect­ively. [5]

   Tumors of the Kidney Top

Tumors of the kidney are usually asympto­matic. Only four to nine percent of patients with renal tumors demonstrate the classic clinical triad of flank pain, gross hematuria, and palpable renal mass. Most renal masses are detected incidentally. Tumors may be misinterpreted as fungus balls, blood clots, fat within the renal sinus, and sloughed papillae.[5] Ultrasound is the most cost-effective approach for detecting renal masses. [60] Indeed, any enhancing solid mass in the kidney should be considered to be a neoplasm until proven otherwise. [18]

On sonography, solid tumors are found as solid iso echoic (86%), hypo echoic or hyper echoic masses, usually without definite contour. Furthermore, cystic lesions with more than two septae, internal calcification, septal thickening, or nodularity are considered to be malignant lesions [17],[18],[61],[62] It should be mentioned that the sonographic appearance of renal lymphoma may vary from perirenal involvement to focal nodules or diffuse parenchymal infiltration. [5]

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Correspondence Address:
Alaleh Gheissari
School of Medicine, Isfahan University of Medical Sciences, Isfahan
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