Renal duplex ultrasound

# Renal Artery Ultrasound

## Indications
- Acute renal failure
- New onset hypertension
- Refractory hypertension
- Abdominal bruit
- Flash pulmonary edema
- Small kidneys
- Post intervention surveillance

## Technical Aspects
The renal arteries may be technically difficult to image.  Large body habitus, excessive bowel gas, and the depth or course of the arteries may all play role in contribute to this difficulty.  Patients should be kept NPO before the procedure.
- Survey the Aorta in transverse orientation.
- Sample Celiac, SMA, IMA
- Image the aorta in long axis.  Document spectral waveform at 60 degrees in the center of the vessel between SMA and renal arteries. This velocity will be used to calculate the Renal/Aortic Ratio (RAR).
- Identify the renal arteries in the transverse plane.  Identify SMA, the renal arteries will be located approximately 1-2 cm below the artery and appear a tubular structures coursing from the abdominal aorta.  Usually, the Left renal vein may be used as a landmark to identify the arteries and will be found as it passes anterior to the aorta.

## Scanning the Renal Arteries
Stenotic lesions will lead to velocity increases and post stenotic turbulence.  Once identified, the artery should be visualized through its entire course.  The sample volume should be kept as small as possible keeping the angle as close to 60 degrees. The greates peak velocity should be documented to facilitate the calculation of RAR.  The Renal wave form is biphasic and LOW RESISTANCE with continuous diastolic flow.  A high resistive signal may indicate renal stenosis or parenchymal disease.

## Scanning the Kidneys
The kidney is composed of two areas, the sinus and parenchyma. The renal parenchyma consists of two areas, an outer cortex and inner medulla. The renal sinus is the central segment of the kidney. The hilum of the renal sinus is where the renal artery enters and  renal vein exits.  The kidneys are measured pole-to-pole. Normal renal size is 9-12 cm, the left renal artery is generally slightly larger.  Presence of any abnormalities (cyst, calculi, fluid, masses) should be noted and reported to ordering physician.  Parenchymal flow should be documented to the upper, middle and lower kidney to rule out AV fistulas, infarcts or other abnormalities.  The resistive index and acceleration time should be documented. Without significant pathology, the pressure waveform should resemble the renal artery ie..LOW RESISTIVE.  A high resistive profile may indicate renal parychymal disease or lobar artery occlusion.  The renal vein should also be interrogated through its course.

# Diagnostic Criteria
(may vary from institution to institution. Must be validated)

## RENAL PARYNCHYMA

### Resistive Index (RI)
- Normal Values:   0.53.  Increases in RI may indicate intrinsic Kidney disease.
- Acceleration Time:  Time from the start of flow to the peak flow.
- Normal Values:  <100 ms.  Increases may suggest renal artery stenosis.
- Size: Normal size 9-12 cm.  A kidney size less than 8 cm or > 1.5 cm difference between the two kidneys is abnormal.

## RENAL ARTERIES
Normal renal arteries have a peak systolic velocity (PSV) of about 100 cm/sec with a LOW RESISTIVE PROFILE  with forward diastolic flow of about 30 cm/sec.

### Renal Artery Ratio (RAR)
- 0-59%          RAR < 3.5 without significant turbulent flow
- 60-99%         PSV > 200 cm/sec; RAR > 3.5 with significant turbulent flow.
- >80%           EDV > 150 cm/sec.
Renal artery occlusion should only be documented with visulation of the renal artery and no color flow or Doppler waveforms.  Kidney size will usually be under 8 cm and parynchymal waveforms and color signal will be markedly reduced.

## Additional Considerations
AAA: Aortic velocities should be documented prior to the aneurysm, at the level of the renal arteries and distal to the anuerysm if possible.  RAR may or may not be accurate in the presence of AAA and this should be noted.
Low Aortic Velocity ( 3 with this situation, then PSV should be > 200 cm/sec in order to report 60-99% stenosis.
High Aortic Velocity (>100 cm/sec) :  RAR may also not be accurate with high aortic velocities as it may falsely lower RAR.
Secondary Criteria to establish significant stenosis if an RAR can not be calculated include:
- PSV>200 cm/sec
- Distal Velocity shift
- Significant turbulence by color doppler
- An Acceleration time > 100m/s