Radiological Imaging of the Kidney (eBook)

Radiological Imaging of the Kidney 3
Dedication 5
Foreword 6
Preface 7
Contents 8
Part I:Embryology and Anatomy 11
1: Embryology of the Kidney 12
1.1 Introduction 12
1.2 Development of Urogenital System 13
1.3 Development of Urinary System 13
1.3.1 Morphogenesis of Transient Kidney 14
1.3.1.1 Pronephroi 14
1.3.1.2 Mesonephroi 14
1.3.2 Morphogenesis of Metanephros or Permanent Kidney 16
1.4 Migration of the Kidneys 18
1.5 Lobes of Kidney Surface 19
1.6 Vascular Variations 19
1.7 Supernumerary Renal Arteries 19
1.8 Molecular Aspects of Kidney Development 19
1.8.1 Inductive Processes and Proliferation 19
1.8.2 Apoptosis 21
1.9 Congenital Abnormalities of the Kidney and Urinary Tract 21
1.9.1 Renal Agenesis (Fig. 1.7a) 21
1.9.2 Hypoplastic Kidney 21
1.9.3 Ectopic Kidney (Fig. 1.7b–e) 21
1.9.4 Fused/Horseshoe Kidney 23
1.9.5 Ectopic Ureter 23
1.9.6 Duplications of the Urinary Tract 23
1.9.7 Wilms Tumor 23
1.10 Conclusions 23
References 24
2: Normal Radiological Anatomy and Anatomical Variants of the Kidney 25
2.1 Anatomy and Physiology of the Kidney 25
2.1.1 Normal Renal Anatomy 25
2.1.1.1 Macroscopic Renal Anatomy 25
2.1.1.2 Microscopic Renal Anatomy and Nephron Physiology 29
2.1.2 Normal Renal Physiology 32
2.1.3 Calculation of Glomerular Filtration Rate (GFR) 33
2.1.4 Calculation of Glomerular Filtration Rate (GFR) in Acute Renal Failure 36
2.2 Normal Radiological Anatomy of the Renal Parenchyma, Intrarenal Vasculature, and Anatomical Variants 37
2.2.1 Conventional Radiography 37
2.2.2 Gray-Scale and Doppler Ultrasound 38
2.2.3 Computed Tomography 41
2.2.4 Magnetic Resonance Imaging 44
2.2.5 Anatomical Variants of Renal Morphology 45
2.2.6 Anatomical Variants of Renal Parenchyma 47
2.3 Normal Radiological Anatomy of Renal Vessels and Anatomical Variants 52
2.3.1 Gray-Scale and Doppler Ultrasound 54
2.3.2 CT Angiography 54
2.3.3 MR Angiography 56
2.3.4 Anatomical Variants of Renal Vessels 57
2.4 Normal Radiological Anatomy of the Urinary Tract and Anatomical Variants 62
2.4.1 Excretory Urography and Anterograde and Retrograde Pyelography 62
2.4.2 CT Urography 63
2.4.3 Magnetic Resonance Imaging and MR Urography 63
2.4.4 Anatomical Variants of the Urinary Tract 67
2.5 Appendix: Basic Morphological Changes of the Intrarenal Urinary Tract Visible on Intravenous Excretory Urography and Mult 76
References 84
3: Normal Radiological Anatomy of the Retroperitoneum 86
3.1 Normal Anatomy of Retroperitoneum 86
References 90
Part II:Imaging and Interventional Modalities 91
4: Ultrasound of the Kidney 92
4.1 Technology 93
4.2 Ultrasound Scanning Technique of the Kidneys 95
4.2.1 Gray-Scale Ultrasound 95
4.2.1.1 Normal Anatomy 95
4.2.1.2 Fundamental Alterations of Renal Echogenicity 97
4.2.1.3 Solid and Cystic Renal Tumors 98
4.2.2 Color and Power Doppler Ultrasound 106
4.2.2.1 Normal Anatomy 106
4.2.2.2 Fundamental Alterations of Renal Parenchyma Vascularity 108
4.2.2.3 Renal Tumors 109
4.2.2.4 Assessment of Renal Vessels 111
4.3 Clinical Indications for Renal Ultrasound Examination 116
4.4 Microbubble Contrast Agents and Contrast-Specific Ultrasound Techniques 117
4.4.1 Chemical Composition of Microbubble Contrast Agents 118
4.4.2 Safety 119
4.4.3 Insonation Power 120
4.4.4 Contrast-Specific Ultrasound Techniques 120
4.5 Dynamic Phases After Microbubble Injection in the Kidney 123
4.5.1 Dynamic Phases 123
4.5.2 Microbubble Artifacts 123
4.6 Clinical Applications of Microbubble Contrast Agents in the Kidney 124
References 130
5: Computed Tomography 133
5.1 General Concepts 133
5.1.1 Technical Parameters 135
5.1.1.1 Imaging 135
5.1.1.2 Artifacts 137
5.1.1.3 Radiation Dose 140
5.1.2 Unenhanced and Contrast-Enhanced CT 143
5.1.2.1 Patient Preparation 143
5.1.2.2 Unenhanced CT 143
Precontrast Scan 143
Renal Colic (Acute Flank Pain) 144
5.1.2.3 Contrast-Enhanced CT 148
CT Examination of Renal Masses 151
CT Examination of Renal Traumas 154
CT Examination of the Postoperative Kidney 157
5.1.3 CT Nephrogram Alterations 157
5.1.3.1 Delayed CT Nephrogram 158
5.1.3.2 Increased Density of CT Nephrogram 158
5.1.3.3 Decreased Density or Absence of CT Nephrogram 158
5.1.3.4 Cortical (Rim) Nephrogram 162
5.2 Multidetector CT Urography and CT Angiography 164
5.2.1 Multidetector CT Urography 165
5.2.1.1 Technique 165
5.2.1.2 Optimizing Excretory Phase 167
5.2.1.3 Reconstruction Algorithms 170
5.2.1.4 Radiation Dose 170
5.2.1.5 Indications 174
5.2.2 CT Angiography 176
5.2.3 Dual-Energy CT 177
References 178
6: Magnetic Resonance Imaging of the Kidney 182
6.1 Technique 183
6.1.1 Equipment 183
6.1.2 Patient Positioning 183
6.1.3 Breath Holding 183
6.1.4 Sequences 183
6.2 Magnetic Resonance Appearance of Renal Diseases 187
6.2.1 Renal Cell Carcinoma 187
6.2.2 Urothelial Carcinoma 189
6.2.3 Lymphoma 190
6.2.4 Metastasis 190
6.2.5 Angiomyolipoma 190
6.2.6 Oncocytoma 191
6.2.7 Other Benign Renal Masses 191
6.2.8 Cystic Lesions 191
6.2.9 Renal Infections 194
6.2.10 Renal Artery Stenosis 195
6.3 Renal Transplant 195
6.4 Advanced Applications 196
6.4.1 Magnetic Resonance Angiography Without Gadolinium-Based Contrast Administration 196
6.4.2 Contrast-Enhanced Magnetic Resonance Renography 196
6.4.3 Diffusion MRI and Renal Function 197
6.4.4 BOLD MRI 197
6.4.5 USPIO Particles 197
References 198
7: Renal Angiography and vascular interventional radiology 199
7.1 Introduction 199
7.2 Technique 200
7.2.1 Diagnostic Angiography 200
7.3 Interventional Renal Vascular Procedures 203
7.3.1 Vascular Interventions 203
7.3.2 Other Endovascular Interventions 206
7.3.3 Renal Phlebography 208
7.4 Anatomy and Variants 208
7.4.1 Arteries 208
7.4.2 Veins 211
7.5 Occlusive Disease 211
7.5.1 Atherosclerotic Renal Artery 212
7.5.1.1 Endovascular Treatment of Atherosclerotic Renal Artery Stenosis 215
7.5.2 Fibromuscular Dysplasia (FMD) 215
7.5.2.1 FMD, Variants, and Appearance on Angiography 215
7.5.2.2 Endovascular Treatment of FMD 219
7.5.3 Other Causes 219
7.6 Acute Renal Ischemia 219
7.6.1 Renal Vein Thrombosis 220
7.7 Renal Artery Aneurysms 220
7.8 Arteriovenous Fistulas 222
7.9 Trauma 223
7.10 Renal Transplantation 223
7.11 Neoplasms 225
7.11.1 Benign Tumors 225
7.11.1.1 Angiomyolipoma (AML) 225
7.11.1.2 Oncocytoma 225
7.11.2 Malignant Tumors 225
7.11.2.1 Advanced Renal Cell Carcinomas 225
7.11.2.2 Malignant Lesions 227
References 227
8: Nuclear Medicine 230
8.1 Introduction 230
8.2 Renal Nuclear Medicine Principles 231
8.2.1 Radiopharmaceuticals 232
8.2.1.1 Glomerular-Filtered Agents 232
8.2.1.2 Tubular Excreted Agents 233
8.2.1.3 Cortical Agents 233
8.2.1.4 Oncological Tracers 234
8.2.2 Principal Investigations 234
8.2.2.1 Blood Sampling 234
8.2.2.2 Dynamic Renal Scintigraphy 235
Diuretic Scintigraphy 236
Quantitative Methods 237
8.2.2.3 Static Renal Scintigraphy 237
8.2.2.4 Radionuclide Cystography 238
8.3 Clinical Applications 238
8.3.1 Renal Failure 241
8.3.2 Urinary Tract Dilatation 244
8.3.3 Urinary Tract Infection 246
8.3.4 Renovascular Hypertension 247
8.3.5 Renal Transplantation 249
8.3.6 Renal Cancer 252
References 254
9: The Role of Kidney Biopsy in the Diagnosis of Renal Disease and Renal Masses 257
9.1 Introduction 258
9.2 Historical Background 258
9.3 Clinical Indications for Renal Biopsy 259
9.3.1 Major Indications 259
9.3.1.1 Idiopathic Nephrotic Syndrome 259
9.3.1.2 Acute Renal Injury 260
9.3.1.3 Renal Allograft Dysfunction 260
9.3.2 Optional Indications 260
9.3.2.1 Persistent Nonnephrotic Proteinuria 260
9.3.2.2 Isolated Glomerular Hematuria 261
9.3.2.3 Chronic Kidney Injury 261
9.4 Contraindications to the Renal Biopsy 261
9.5 The Preparation of the Patient for Renal Biopsy 262
9.5.1 The Patient Before the Biopsy 262
9.6 The Biopsy Procedure 263
9.6.1 The Choice of the Biopsy Site 263
9.6.2 Biopsy Needle Types 263
9.6.3 Evaluation and Division of the Biopsy Tissue 264
9.6.4 Fixatives for Preservation of the Biopsy Tissue 264
9.7 Percutaneous Biopsy of Renal Masses 264
9.7.1 Indications 264
9.7.2 Technique 265
9.7.3 Results 267
9.8 Renal Biopsy Complications and Follow-Up 267
References 269
10: Nonvascular Interventional Radiology Procedures 271
10.1 Introduction 272
10.2 Imaging Modalities and Interventional Equipment 272
10.2.1 Imaging Modalities 272
10.2.1.1 Fluoroscopy 272
10.2.1.2 Ultrasonography 273
10.2.1.3 CT 273
10.2.1.4 Interventional MRI 274
10.2.2 Interventional Equipment Tools 274
10.2.2.1 Needles 274
10.2.2.2 Guidewires 275
10.2.2.3 Catheters 275
10.3 Renal Biopsy 275
10.3.1 Indications 275
10.4 US- and CT-Guided Drainage of Renal and Perirenal Collections 277
10.4.1 Indications 277
10.4.2 Preparation 277
10.4.3 Techniques 277
10.4.4 Success Rate 278
10.4.5 Complications 279
10.5 Percutaneous Nephrostomy 279
10.5.1 Indications 279
10.5.2 Preparation 279
10.5.3 Technique 279
10.5.4 Success Rate 279
10.5.5 Complications 279
10.6 Percutaneous Lithotripsy and Nephrolithotomy 280
10.6.1 Indications 280
10.6.2 Preparation 280
10.6.3 Technique 280
10.6.4 Success Rate 281
10.6.5 Complications 281
10.7 Ureteral Stenting 281
10.7.1 Indications 281
10.7.2 Preparation 281
10.7.3 Techniques 281
10.7.4 Success Rate 282
10.7.5 Complications 283
10.8 Ureteral Ballooning of Strictures 283
10.8.1 Indications 283
10.8.2 Preparation 283
10.8.3 Techniques 283
10.8.4 Success Rate 283
10.8.5 Complications 283
10.9 Ureteral Embolization 284
10.9.1 Indications 284
10.9.2 Preparation 284
10.9.3 Techniques 284
10.9.4 Success Rate 285
10.9.5 Complications 285
10.10 Sovrapubic Tube Placement 285
10.10.1 Indications 285
10.10.2 Preparation 286
10.10.3 Techniques 286
10.10.4 Success Rate 286
10.10.5 Complications 286
10.10.6 Conclusion 286
References 286
Part III:Non-Tumoral Pathology 288
11: Congenital and Development Disorders of the Kidney 289
11.1 Embryology of the Kidneys, Ureters and Bladder 289
11.2 Positional and Fusion Anomalies 290
11.2.1 Ectopic Kidney 290
11.2.2 Horseshoe Kidneys 290
11.2.3 Crossed Fused Ectopia 291
11.3 Renal Agenesis and Anomalies in Size 291
11.3.1 Renal Agenesis 291
11.3.2 Renal Hypoplasia 293
11.4 Renal Cystic Disease 293
11.4.1 Renal Cystic Disease of Developmental Origin 293
11.4.1.1 Multicystic Dysplastic Kidney 293
11.4.1.2 Cystic Renal Dysplasia 295
11.4.2 Renal Cystic Disease of Genetic Origin 295
11.4.2.1 Autosomal Recessive Polycystic Kidney Disease 295
11.4.2.2 Autosomal Dominant Polycystic Kidney Disease 297
11.4.2.3 Medullary Cystic Disease and Nephronophthisis 297
11.4.2.4 Glomerulocystic Kidney Disease 298
11.5 Renal Tract Dilatation 299
11.5.1 Renal Pelvis Dilatation 299
11.5.2 Renal Pelvis and Ureter Dilatation 300
11.5.3 Duplex Kidney with Ureter Dilatation 302
11.5.4 Posterior Urethral Valves 304
11.5.5 Prune Belly Syndrome 304
11.6 Congenital Renal Tumours 306
References 307
12: Renal Cystic Disease 309
12.1 Introduction 309
12.2 Simple Cysts 312
12.3 Complex Cysts 313
12.4 Extraparenchymal Renal Sinus Cysts 315
12.5 Localized Cystic Disease 318
12.6 Acquired Cystic Kidney Disease 318
12.7 Polycystic Kidney Diseases 320
12.7.1 Autosomal Dominant Polycystic Kidney Disease 320
12.7.2 Autosomal Recessive Polycystic Kidney Disease 324
12.8 Renals Cysts in Hereditary Malformation Syndromes 324
12.8.1 Tuberous Sclerosis Complex 324
12.8.2 von Hippel–Lindau Disease 326
12.9 Medullary Sponge Kidney 326
12.10 Multicystic Dysplastic Kidney 328
12.11 Chronic Lithium Nephropathy 330
References 332
13: Renal Parenchymal and Inflammatory Diseases 336
13.1 Glomerulonephritis, Tubulo-Interstitial Nephritis, and Vasculitides 337
13.1.1 Glomerulonephritis and Tubulo-Interstitial Nephritis 338
13.1.2 Renal Vasculitides 339
13.2 Systemic Diseases Involving the Kidney 339
13.2.1 Diabetic Nephropathy 339
13.2.2 Hypertension 342
13.2.3 Lupus Systemic Erythematosus 343
13.2.4 Metabolic and Hematological Disease-Related Nephropathies 344
13.2.5 HIV-Associated Nephropathy 346
13.3 Drug Nephropathies 347
13.4 Pediatric Renal Parenchymal Diseases 347
13.5 Renal Medullary and Papillary Necrosis 348
References 353
14: Obstructive Uropathy, Pyonephrosis, and Reflux Nephropathy in Adults 354
14.1 Obstructive Uropathy 356
14.1.1 Imaging Findings 356
14.1.1.1 Ultrasound 356
14.1.1.2 Unenhanced Spiral CT 357
14.1.1.3 Intravenous Excretory Urography and CT Urography 358
14.1.1.4 MR Urography 361
14.1.2 Causes of Obstruction 363
14.1.2.1 Congenital Anomalies 363
14.1.2.2 Ureteropelvic Junction Obstruction 365
14.1.2.3 Urolithiasis and Acute Renal Colic 365
14.1.2.4 Other Benign Causes of Obstructive Uropathy 369
14.1.2.5 Malignancies Causing Obstructive Uropathy 376
14.1.3 Obstructive Nephropathy and Postrenal Acute Renal Failure 377
14.2 Pyonephrosis 378
14.3 Reflux Nephropathy in Adults 381
References 388
15: Nephrocalcinosis and Nephrolithiasis 391
15.1 Introduction 391
15.2 Nephrocalcinosis 392
15.2.1 Causes and Incidence of Nephrocalcinosis 392
15.2.2 Cortical Nephrocalcinosis 392
15.2.3 Medullary Nephrocalcinosis 394
15.2.3.1 Abnormal Calcium Metabolism 394
15.2.3.2 Renal Tubular Diseases 394
15.2.3.3 Medullary Sponge Kidney 395
15.3 Nephrolithiasis 395
15.3.1 Incidence and Epidemiology 397
15.3.1.1 Race and Sex 397
15.3.1.2 Age 397
15.3.1.3 Inherited Diseases 397
15.3.1.4 Individual Predisposing Factors 397
15.3.1.5 Environmental Factors 398
15.3.1.6 Socio-Economic Factors 398
15.3.1.7 Diet 398
15.3.2 Pathophysiology 398
15.3.3 Types of Calculi 398
15.3.3.1 Calcium Calculi 398
15.3.3.2 Cystine Stones 398
15.3.3.3 Struvite or Infective Calculi 399
15.3.3.4 Uric Acid Calculi 399
15.3.3.5 Xanthine Calculi 399
15.3.3.6 Matrix Calculi 399
15.3.3.7 Indinavir Calculi 400
15.3.3.8 Oxalate Calculi 400
15.4 Imaging 400
15.4.1 Background and Principles 400
15.4.2 Abdominal Radiographs 400
15.4.3 Intravenous Excretory Urography 401
15.4.4 Ultrasound 402
15.4.5 Computed Tomography 404
15.4.5.1 Unenhanced CT 405
15.4.5.2 CT Urography 408
15.4.6 Other Techniques 409
References 410
16: Acute Renal Infections 412
16.1 Acute Bacterial Pyelonephritis 413
16.1.1 Clinical Features and Pathophysiology 413
16.1.2 Imaging 415
16.1.2.1 IVU 416
16.1.2.2 US 416
16.1.2.3 CT 418
16.1.2.4 Nuclear Medicine 420
16.1.2.5 MRI 425
16.2 Renal and Perinephric Abscess 430
16.2.1 Clinical Features and Pathophysiology 430
16.2.2 Imaging 431
16.3 Gas-Forming Renal Infections 433
16.3.1 Emphysematous Pyelonephritis 434
16.3.2 Emphysematous Pyelitis 436
References 437
17: Chronic Renal Infections and Renal Fungal Infections 440
17.1 Chronic Pyelonephritis 441
17.2 Renal Tuberculosis 443
17.3 Xanthogranulomatous Pyelonephritis 445
17.4 Renal Replacement Lipomatosis 450
17.5 Renal Malacoplakia 451
17.6 Cholesteatoma 456
17.7 Renal Infections in AIDS Patients 456
17.8 Renal Fungal Infections 459
References 468
18: Renal Vascular Abnormalities 469
18.1 Renal Vascular Abnormalities 469
18.2 Arterial Disease 470
18.2.1 Renovascular Hypertension 470
18.2.1.1 Atherosclerosis 470
18.2.2 Renal Artery Stenosis (RAS) 470
18.2.2.1 Fibromuscular Dysplasia 471
18.2.2.2 Takayasu’s Aortitis 473
18.2.2.3 Neurofibromatosis 473
18.2.2.4 Middle Aortic Syndrome 473
18.3 Diseases of the Intrarenal Arteries 474
18.3.1 Polyarteritis Nodosa (PAN) 474
18.3.2 Wegener’s Granulomatosis 474
18.3.3 Systemic Lupus Erythematosus (SLE) 474
18.3.4 Intravenous Drug Abuse 474
18.3.5 Scleroderma 475
18.3.6 Radiation Nephritis 475
18.3.7 Embolism and Infarction 475
18.3.8 Arterial Thrombosis 475
18.3.9 Renal Artery Aneurysm 475
18.3.10 Arteriovenous Fistula and Malformations (AVF and AVM) 476
18.4 Venous Disease 477
18.4.1 Renal Vein Thrombosis (RVT) 477
18.4.2 Varicocele Formation 477
18.4.3 Gonadal Vein Thrombosis 478
18.4.4 Renal Lymphangiomatosis 478
References 478
19: Imaging of Renal Trauma 480
19.1 Renal Injury Overview 481
19.2 Hematuria and Hemodynamic Stability 481
19.3 Penetrating Renal Trauma 481
19.4 Renal Injury Grading 482
19.5 Injury Grading and Intervention 483
19.6 CT Findings of Renal Injury 483
19.6.1 Minor: Contusion – Laceration 483
19.6.2 Minor: Focal Renal Infarct 484
19.6.3 Minor: Subcapsular Hematoma 484
19.7 CT Finding of Major Renal Injury 484
19.7.1 Urine Leaks 485
19.7.2 Hematoma 486
19.7.3 Parenchymal Disruption 486
19.8 CT of Catastrophic Renal Injury 486
19.8.1 Vascular Injury 486
19.8.2 Bleeding 491
19.8.3 Collecting System Injury 491
19.9 Injury of the Abnormal Kidney 494
19.10 Imaging Findings and Management 495
19.11 Complications of Renal Injury 496
19.11.1 Persistent Urinoma 496
19.11.2 Hypertension 496
19.12 Conclusion 498
References 498
Part IV:Tumoral Pathology 500
20: Benign Solid Renal Tumors 501
20.1 Angiomyolipoma 504
20.2 Renal Cell Neoplasms 515
20.2.1 Oncocytoma 515
20.2.2 Renal Papillary Adenoma 519
20.3 Other Benign Solid Renal Tumors 521
20.3.1 Embryonal Metanephric Adenoma 521
20.3.2 Benign Solid Tumors in Phakomatoses 526
20.3.3 Arteriovenous Fistulas and Intra-Renal Vascular Malformations 528
20.3.4 Rare Solid Benign Tumors 529
References 532
21: Renal Cell Carcinoma 534
21.1 Introduction 535
21.2 Histopathological Subtypes 535
21.3 Imaging of Conventional (Clear Cell) Renal Cell Carcinoma 536
21.3.1 Plain Radiography 536
21.3.2 Intravenous Urography 537
21.3.3 Ultrasound 537
21.3.4 Computed Tomography 538
21.3.5 Magnetic Resonance Imaging 541
21.3.6 Positron Emission Tomography 542
21.3.7 Angiography 542
21.4 Imaging of Uncommon Renal Cell Carcinoma 544
21.4.1 Papillary Type 545
21.4.2 Chromophobe Cell Type 546
21.4.3 Collecting Duct Type 547
21.4.4 Medullary Type 547
21.4.5 Sarcomatoid Type 548
21.4.6 Hypovascular or Avascular Renal Cell Carcinoma 548
21.5 Hereditary Renal Cell Carcinoma 548
21.5.1 von Hippel-Lindau Disease 549
21.5.2 Hereditary Papillary Renal Cancer 550
21.5.3 Hereditary Leiomyoma Renal Cell Carcinoma 550
21.5.4 Birt-Hogg-Dubé Syndrome 550
21.5.5 Familial Renal Oncocytoma 550
21.5.6 Tuberous Sclerosis 550
21.6 Staging of Renal Cell Carcinoma 550
21.6.1 Imaging Modalities for Staging 550
21.6.2 Follow-Up Imaging 552
21.7 Imaging of Metastases and Recurrence 553
21.8 An Overview of Role of Biopsy and Interventional Techniques 554
21.8.1 Percutaneous Biopsy of Renal Masses 554
21.8.2 Radiofrequency Ablation 555
21.8.3 Transarterial Embolization 557
21.8.4 Nephron-Sparing Surgery 558
21.9 Conclusion 559
References 560
22: Rare and Secondary Tumors of the Kidney and Renal Pseudotumors 564
22.1 Secondary Tumors of the Kidney 564
22.1.1 General Features 565
22.1.2 Imaging Features and Differential Diagnosis 565
22.2 Other Rare Renal Tumors 566
22.2.1 Medullary Tumors 566
22.2.1.1 Collecting (Bellini) Duct Carcinoma (CDC) 566
General Features and Pathogenesis 566
Imaging Features and Differential Diagnosis 566
22.2.1.2 Renal Medullary Carcinoma 568
General Features 568
Imaging Features and Differential Diagnosis 568
22.2.2 Juxtaglomerular Cell Tumor (Reninoma) 568
22.2.3 Solitary Fibrous Tumor 569
22.2.4 Leukemia, Plasmocytoma, Castleman Disease and Lymphoma 570
22.2.4.1 Leukemia 570
22.2.4.2 Plasmacytoma 570
22.2.4.3 Castleman Disease 570
22.2.4.4 Lymphoma 570
22.2.5 Sarcoma 570
22.2.6 Rare Benign Mesenchymal Tumors of the Kidney 570
22.2.6.1 Renal Leiomyoma 570
22.2.6.2 Renal Lipoma 571
22.2.6.3 Renal Hemangioma 571
22.2.6.4 Renal Lymphangioma 571
22.2.7 Extraadrenal Myelolipoma 571
22.2.8 Mesoblastic Nephroma 571
22.2.9 Metanephric Adenoma (Nephrogenic Adenofibroma) 572
22.2.10 Multilocular Cystic Tumor 572
22.2.11 Neuro-Endocrine Tumor (NET) of the Kidney 572
22.2.12 Extraintestinal GIST 573
22.3 Renal Pseudotumors 573
22.3.1 Infection 573
22.3.1.1 Classical Presentation 573
22.3.1.2 Xanthogranulomatous Pyelonephritis 575
22.3.1.3 Renal Tuberculosis 575
22.3.1.4 Renal Aspergillosis 576
22.3.1.5 Hydatid Cyst of the Kidney 577
22.3.2 Renal Malacoplakia 577
22.3.3 Renal Hematoma 577
22.3.4 Renal Sarcoidosis 577
22.3.5 Renal Amyloidosis 577
22.3.6 Renal Sinus Histocytosis 579
22.3.7 Systemic Lupus Erythematosus 579
22.3.8 Perirenal Fibrosis and Erdheim–Chester Disease 579
22.3.8.1 Perirenal Fibrosis 579
22.3.8.2 Erdheim–Chester Disease 579
22.3.9 Inflammatory Pseudotumor 580
22.3.10 Renal Sinus Lipomatosis 581
22.3.11 Extramedullary Hematopoiesis 581
22.3.12 Congenital and Acquired Pseudotumors 581
22.3.13 Vascular Anomalies 582
22.3.14 Hemorrhagic Cysts 582
References 583
23: Radiofrequency Ablation and Cryoablation for Renal Cell Carcinoma 585
23.1 Indications 586
23.2 Patient Selection 586
23.3 Procedure 587
23.3.1 Radiofrequency Ablation 587
23.3.2 Cryoablation 587
23.3.3 Emerging Technologies 588
23.3.4 Difficulties Comparing Modalities and Approaches 588
23.3.5 Adjuvant Therapy 589
23.3.6 Biopsy Controversy 589
23.3.7 Day of the Procedure 589
23.4 Outcomes and Complications 590
23.4.1 Imaging Follow-Up 590
23.4.2 Imaging Pitfalls 590
23.4.3 Outcomes 590
23.4.3.1 Outcomes for Radiofrequency Ablation 591
23.4.3.2 Outcomes for Cryoablation 591
23.4.4 Complications 592
23.5 Conclusion 593
References 593
24: Upper Urinary Tract Tumors 595
24.1 Pathology and Histology of Transitional Cell Carcinoma 596
24.2 Imaging 597
24.2.1 Imaging of Upper Tract Urinary Tumors 597
24.2.1.1 Ultrasonography 597
24.2.1.2 Intravenous Excretory Urography 598
24.2.1.3 Anterograde and Retrograde Pyelography 599
24.2.1.4 Multidetector CT Urography 601
24.2.1.5 CT 604
24.2.1.6 MR Imaging 607
24.2.2 Imaging of Hematuria 609
24.3 Staging of Upper Urinary Tract Tumors 613
24.4 Follow-Up 614
24.5 Other Malignant Tumors of the Upper Urinary Tract 614
24.6 Differential Diagnosis 615
24.7 Benign Tumors of the Upper Urinary Tract 616
References 618
25: Renal Lymphoma and Renal Sarcoma 621
25.1 Renal Lymphoma 622
25.1.1 General Features 622
25.1.2 Pathogenesis 622
25.1.3 Imaging Features and Differential Diagnosis 622
25.1.3.1 Multiple Masses 622
25.1.3.2 Retroperitoneal Extension 623
25.1.3.3 Infiltrative Disease 624
25.1.3.4 Solitary Mass 624
25.1.3.5 Perirenal Disease 624
25.1.3.6 Atypical Findings 625
25.1.4 Roll of Different Imaging Modalities 625
25.1.4.1 Ultrasound 625
25.1.4.2 Computed Tomography and Positron Emission Tomography-Computed Tomography (PET-CT) 625
25.1.4.3 MRI 626
25.1.5 Diagnostic Approach 626
25.2 Renal Sarcoma 626
25.2.1 General Features 626
25.2.2 Pathogenesis 626
25.2.3 Imaging Features 626
25.2.3.1 Liposarcoma 627
25.2.3.2 Hemangiopericytoma and Angiosarcoma 627
25.2.3.3 Malignant Fibrous Histiocytoma and Fibrosarcoma 627
25.2.3.4 Leiomyosarcoma and Rhabdomyosarcoma 627
25.2.3.5 Osteosarcoma, Chondrosarcoma, Ewing Sarcoma, and Synovial Sarcoma 628
25.2.3.6 Granulocytic Sarcomas (Chloromas) 629
25.2.3.7 Kaposi Sarcoma 630
25.2.4 Diagnostic Approach 630
References 632
26: Cystic Renal Masses 634
26.1 Introduction 635
26.2 Definition and Etiology of Cystic Renal Masses 635
26.2.1 Definition 635
26.2.2 Etiologies 635
26.2.2.1 Benign Nonneoplastic Cystic Masses 635
26.2.2.2 Benign Cystic Neoplasms (Fig. 26.1) 635
26.2.2.3 Malignant Cystic Neoplasms (Fig. 26.1) 637
Multilocular Cystic RCC of Low Malignant Potential 637
Clear Cell or Papillary RCCs with Cystic Changes 637
Tubulocystic Carcinoma 637
26.3 Imaging Techniques and Key Interpretation Criteria 638
26.3.1 Conventional Ultrasound 638
26.3.2 Contrast-Enhanced Ultrasound 639
26.3.3 Computed Tomography 640
26.3.4 MR Imaging 641
26.4 The Bosniak Classification System 643
26.4.1 Field of Utilization 644
26.4.2 Bosniak Categories (Fig. 26.10 Table 26.1)
26.4.2.1 Category I Lesions (Fig. 26.12) 646
26.4.2.2 Category II Lesions (Figs. 26.13–26.15) 646
26.4.2.3 Category IIF Lesions (Fig. 26.17) 648
26.4.2.4 Category III Lesions (Figs. 26.18 and 26.19) 650
26.4.2.5 Category IV Lesions (Figs. 26.20 and 26.21) 651
26.4.3 Utility and Limitations of the Bosniak Classification System 652
26.5 Indeterminate Renal Masses and Misclassified Cysts 652
26.5.1 Very Small Renal Mass 653
26.5.2 Renal Mass with Indeterminate Attenuation 653
26.5.3 Renal Mass with Indeterminate “Enhancement” 655
26.5.4 Renal Cyst with Discrepant Findings Between CT and Other Modalities 657
References 658
Part V:Special Topics 661
27: The Pediatric Kidney 662
27.1 General Remarks on the Principles of Imaging Children and Radiation Protection Issues 663
27.2 Vesicoureteral Reflux and Reflux Nephropathy 666
27.2.1 General Considerations 666
27.2.2 Methods for Vesicoureteral Reflux Assessment 667
27.2.2.1 Ultrasound 667
27.2.2.2 Voiding Cystourethrography 670
27.2.2.3 Radionuclide Cystography (RNC) 671
27.2.3 Imaging Algorithm – When to Perform What in Whom 671
27.3 Childhood Urinary Tract Infection, Including (Acute) Pyelonephritis 671
27.3.1 Which Imaging Modalities are Available and How Do Things Look Like? 672
27.3.2 Imaging Algorithm in Pediatric Urinary Tract Infection 675
27.4 Congenital Hydronephrosis and Urinary Tract Obstruction 676
27.4.1 Congenital Hydronephrosis 676
27.4.2 Imaging Algorithm for Congenital Hydronephrosis 676
27.4.3 Obstructive Uropathy 676
27.4.4 Imaging Algorithm in Obstructive Uropathy 678
27.5 Childhood Urolithiasis and Nephrocalcinosis (see also Chap. 15) 680
27.5.1 Urolithiasis 680
27.5.2 Nephrocalcinosis 683
27.6 Pediatric Renovascular Disorders (General Renovascular Disorders) (see Chap. 18) 684
27.6.1 Pediatric Renal Artery Stenosis 684
27.6.2 The Hemolytic-Uremic Syndromes 684
27.6.3 Renal Vein Thrombosis 685
27.6.4 Other Pediatric Vascular Conditions 686
27.7 Renal Neoplasms in Childhood (see also Chaps. 20–26) 686
27.7.1 Imaging Benign Renal Tumors in Children 687
27.7.2 Indeterminate Renal Masses 689
27.7.3 Malignant Tumors 690
27.8 Other Renal Parenchymal Disease and Miscellaneous Renal Disorders 693
27.8.1 Pediatric Cystic Renal Disease 693
27.8.2 Pediatric Renal Parenchymal Disease 693
27.8.3 Acute and Chronic Renal Failure 694
27.8.4 Imaging in Childhood Renal Trauma 695
27.9 Conclusion 696
References 696
28: The Kidney in the Elderly 701
28.1 Morphologic Alterations in the Kidney of an Elderly Patient 703
28.2 Nephrosclerosis 704
28.3 Renovascular Disease 707
28.4 Renal Infarction 711
28.5 Atheroembolic Renal Disease 712
28.6 Renal Vein Thrombosis 715
28.7 Renal Failure 716
28.7.1 Acute Renal Failure 716
28.7.2 Chronic Renal Failure 717
28.8 Obstructive Uropathy 720
28.9 Renal Infections 720
28.10 Neoplastic Pathologies 724
References 729
29: Renal Failure 731
29.1 Acute Renal Failure 732
29.1.1 Prerenal and Renal Acute Renal Failure 733
29.1.2 Postrenal Acute Renal Failure 736
29.1.3 Clinical Scenarios Related to ARF 738
29.2 Chronic Renal Failure 741
29.2.1 Classification 741
29.2.2 Clinical Scenarios Related to Chronic Renal Failure 742
References 746
30: Renal Transplantation 748
30.1 Epidemiology 748
30.2 Presurgical Evaluations 749
30.2.1 Evaluation of the Graft Recipient 749
30.2.1.1 The Lower Urinary Tract 749
30.2.1.2 Status of the Vasculature 749
30.2.2 Evaluation of the Donor 749
30.2.2.1 Evaluation of Cadaveric Donor Kidneys 749
30.2.2.2 Evaluations of Living-Donor Kidneys 750
30.3 Current Surgical Techniques 750
30.3.1 Graft Preservation 750
30.3.2 Transplantation 750
30.4 Radiological Assessment of the Graft 750
30.5 Early Graft Complications (First Year) 754
30.5.1 Urological Complications 754
30.5.1.1 Urinary Fistulas 754
30.5.1.2 Ureteral Stenosis 756
30.5.1.3 Graft Infection 756
30.5.1.4 Perigraft Fluid Collections 756
30.5.2 Vascular Complications 760
30.5.2.1 Renal Artery Thrombosis 760
30.5.2.2 Infarctions 762
30.5.2.3 Renal Artery Stenosis 762
30.5.2.4 Renal Vein Thrombosis 764
30.5.2.5 Vascular Complications of Biopsy 765
30.5.2.6 Parenchymal Necrosis 765
30.5.3 Medical Complications 766
30.5.3.1 Clinical Considerations 766
30.5.3.2 Imaging 770
30.6 Long-Term Follow-Up 771
30.6.1 Chronic Allograft Nephropathy (CAN) 771
30.6.2 Recurrence of the Initial Nephropathy 771
30.6.3 Calculus Disease 772
30.6.4 Solid Tumors 772
30.6.5 Lymphoproliferative Disorders/PTLD 772
30.7 Conclusion 773
References 774
31: Imaging of Dialysis 777
31.1 Uremic Syndrome 778
31.1.1 Electrolyte Alterations 778
31.1.2 Extrarenal Disorders 779
31.2 Acquired (Dialysis-Associated) Cystic Kidney Disease 781
31.3 Dialysis Access Complications 787
31.3.1 Arteriovenous Fistulas 788
31.3.2 Arteriovenous Grafts 789
31.3.3 Dialysis Access Catheters 790
References 792
32: Imaging of the Postoperative Kidney 794
32.1 Management of Renal Masses 794
32.2 Renal Surgery 796
32.2.1 Radical Nephrectomy 796
32.2.2 Partial Nephrectomy: Nephron-Sparing Surgery 797
32.3 Complications After Renal Surgery 801
32.3.1 Complications After Radical Nephrectomy 801
32.3.2 Complications After Partial Nephrectomy 802
32.4 Tumoral Recurrence and Distant Metastases 806
32.4.1 Tumoral Recurrence After Radical Nephrectomy 807
32.4.2 Tumoral Recurrence After Partial Nephrectomy 807
32.4.3 Distant Metastases 808
References 811
33: Contrast Media-Induced Nephropathy and Nephrogenic Systemic Fibrosis 813
33.1 Introduction 814
33.2 Contrast Media-Induced Nephropathy 814
33.2.1 Definition 814
33.2.2 Incidence 814
33.2.3 Clinical Features 815
33.2.4 Risk Factors 815
33.2.4.1 Patient-Related Risk Factors 815
33.2.4.2 Procedure-Related Risk Factors 816
33.2.4.3 Coexistence of Multiple Risk Factors 817
33.2.5 Strategies for Risk Reduction 817
33.2.5.1 Hydration Protocols 817
33.2.5.2 Pharmacologic Agents and Withdrawal of Nephrotoxic Drugs 818
33.2.5.3 Hemodialysis and Hemofiltration 818
33.2.5.4 Choice of Contrast Material Type and Dose 818
33.2.6 Open Questions 818
33.2.7 Guideline 819
33.3 Nephrogenic Systemic Fibrosis 819
33.3.1 Definition 819
33.3.2 Clinical Features 819
33.3.3 Risk Factors 819
33.3.4 The Role of Contrast Material 820
33.3.5 Diagnosis 821
33.3.6 Therapy 823
33.3.7 Guideline 823
33.4 Conclusion 824
References 824
34: Functional Imaging of the Kidney 827
34.1 Contrast Agents and Technical Issues 828
34.1.1 Sonography 828
34.1.2 CT 828
34.1.3 MR Imaging 829
34.2 Measurement of Glomerular Filtration 829
34.2.1 Measurement of Split Renal Function 830
34.2.2 MR Quantification of Global GFR 830
34.2.3 MR Quantification of Single Kidney GFR (SKGFR) 831
34.2.3.1 Monitoring of Tracer Intrarenal Kinetics 831
MR Technical Requirements 832
Postprocessing 833
Compartment Models 834
Accuracy and Reproducibility 834
34.2.3.2 Single Kidney Extraction Fraction 834
34.3 Renal Flow Rate and Renal Perfusion 836
34.3.1 Renal Flow Rate 837
34.3.2 Renal Perfusion 837
34.3.2.1 Ultrasound 837
34.3.2.2 MRI 837
Dynamic MR Imaging 838
Renal Perfusion Using Spin-Labeling 840
34.4 Tubular Function 841
34.4.1 Intratubular Concentration of Diffusible Gd-Chelate 841
34.4.2 Intratubular Transit of Macromolecular Gd-Chelate (T1 Effect) 841
34.5 Urinary Excretion and Renal Transit Time 844
34.6 Angiotensin Converting Enzyme (ACE) Inhibitor-Sensitized MR Renography 844
34.7 Intrarenal Oxygenation 845
34.8 Renal Diffusion 846
References 848
35: Molecular Imaging and Tumoural Antigen Targeting 852
35.1 Pre-Clinical Molecular Imaging 852
35.1.1 Basic Principles of Nuclear Medicine Techniques 853
35.1.1.1 Small Animal PET (SA-PET) 853
35.1.1.2 Small Animal SPECT (SA-SPECT) 854
35.1.2 Basic Principles of Other Molecular Imaging Techniques 855
35.1.2.1 Small Animal Magnetic Resonance Imaging (SA-MRI) 855
35.1.2.2 Optical Imaging 855
35.2 The Kidney: Molecular Imaging and Tumoural Antigen Targeting 856
35.2.1 SA-PET Imaging Methods to Analyse the Renal Function 856
35.2.2 SA-PET for the In Vivo Evaluation of Renal Cell Carcinoma in Animal Models 856
35.2.3 SA-MRI for the In Vivo Tracking of Stem Cells in Animal Models of Renal Impairment 857
References 859
36: Research Perspectives and Future Trends in Renal Imaging 860
36.1 MR Imaging of Cell Targeting 861
36.1.1 Intrarenal Macrophage Activity 861
36.1.2 Principles of MR Targeting of Macrophages 861
36.1.3 Macrophage Targeting in Experimental Models 862
36.1.4 Macrophage Targeting in Humans 864
36.2 MR Imaging of Stem Cell Tracking 865
36.3 MR Imaging and Monitoring of Gene Therapy 868
36.4 Imaging of Cell Receptors 868
36.5 MR Imaging of Enzyme Synthesis or Activity 869
36.5.1 MR Imaging of Matrix Metalloproteases (MMPs) 869
36.5.2 MR Imaging of Myeloperoxidase (MPO) 869
36.6 New Parameters of Renal Function 870
36.6.1 Imaging of Tubule Dysfunction 870
36.6.2 Renal pH MR Imaging 870
36.6.3 Renal Sodium Imaging 870
36.6.4 MR Imaging of Proteinuria 871
36.7 Imaging of Intrarenal Fibrosis 871
36.8 Conclusion 874
References 875
Index 878