Differentiation of delayed kidney graft function with gadolinium-DTPA-enhanced magnetic resonance imaging and Doppler ultrasound

Future of kidney imaging: Functional magnetic resonance imaging and kidney disease progression

INTRODUCTION

Chronic kidney disease (CKD) which is a common cause of death has an increasing trend, but there is no established approach for predicting CKD progression yet. Functional magnetic resonance imaging (fMRI) studies such as blood oxygenation level-dependent MRI (BOLD-MRI), diffusion-weighted MRI (DWI-MRI), diffusion-tensor MRI (DTI-MRI) and arterial spin labelling MRI (ASL-MRI) are rising methods for the assessment of kidney functions in native and transplanted kidneys as well as the estimation of CKD progression.

METHODS

Systematic literature review was performed through the Embase (Elsevier), Cochrane Central Register of Controlled Trials (Wiley), PubMed/Medline and Web of Science databases, and studies investigating the role of fMRI methods assessing kidney functions in native and transplanted kidneys, as well as the value of fMRI methods to predict CKD progression, were included. Working mechanisms, advantages and limitations of the fMRI modalities were reviewed, and three studies investigating the role of fMRI studies in kidney functions were analysed.

RESULTS AND CONCLUSION

BOLD-MRI signal was found to be inversely correlated with annual eGFR change, and DWI/ADC (apparent diffusion coefficient map) values were shown to be correlated with annual eGFR decline. fMRI methods which are currently used for other systems can be utilized to provide more detailed information about kidney functions, and doctors should be ready to interpret kidney MRIs.

MRI for diagnosis of post-renal transplant complications: current state-of-the-art and future perspectives

Kidney transplantation has developed into a widespread procedure to treat end stage renal failure, with transplantation results improving over the years. Postoperative complications have decreased over the past decades, but are still an important cause of morbidity and mortality. Early accurate diagnosis and treatment is the key to prevent renal allograft impairment or even graft loss. Ideally, a diagnostic tool should be able to detect post-transplant renal dysfunction, differentiate between the different causes and monitor renal function during and after therapeutic interventions. Non-invasive imaging modalities for diagnostic purposes show promising results. Magnetic resonance imaging (MRI) techniques have a number of advantages, such as the lack of ionizing radiation and the possibility to obtain relevant tissue information without contrast, reducing the risk of contrast-induced nephrotoxicity. However, most techniques still lack the specificity to distinguish different types of parenchymal diseases. Despite some promising outcomes, MRI is still barely used in the post-transplantation diagnostic process. The aim of this review is to survey the current literature on the relevance and clinical applicability of diagnostic MRI modalities for the detection of various types of complications after kidney transplantation.

Blood oxygen level-dependent and perfusion magnetic resonance imaging: detecting differences in oxygen bioavailability and blood flow in transplanted kidneys

Functional magnetic resonance imaging (fMRI) is a powerful tool for examining kidney function, including organ blood flow and oxygen bioavailability. We have used contrast enhanced perfusion and blood oxygen level-dependent (BOLD) MRI to assess kidney transplants with normal function, acute tubular necrosis (ATN) and acute rejection. BOLD and MR-perfusion imaging were performed on 17 subjects with recently transplanted kidneys. There was a significant difference between medullary R2 values in the group with acute rejection (R2=16.2/s) compared to allografts with ATN (R2=19.8/s; P=.047) and normal-functioning allografts (R2=24.3/s;P=.0003). There was a significant difference between medullary perfusion measurements in the group with acute rejection (124.4+/-41.1 ml/100 g per minute) compared to those in patients with ATN (246.9+/-123.5 ml/100 g per minute; P=.02) and normal-functioning allografts (220.8+/-95.8 ml/100 g per minute; P=.02). This study highlights the utility of combining perfusion and BOLD MRI to assess renal function. We have demonstrated a decrease in medullary R2 (decrease deoxyhemoglobin) on BOLD MRI and a decrease in medullary blood flow by MR perfusion imaging in those allografts with acute rejection, which indicates an increase in medullary oxygen bioavailability in allografts with rejection, despite a decrease in blood flow.

Quantification of renal allograft perfusion using arterial spin labeling MRI: initial results

OBJECTIVE

To quantify renal allograft perfusion in recipients with stable allograft function and acute decrease in allograft function using nonenhanced flow-sensitive alternating inversion recovery (FAIR)-TrueFISP arterial spin labeling (ASL) MR imaging.

METHODS

Following approval of the local ethics committee, 20 renal allograft recipients were included in this study. ASL perfusion measurement and an anatomical T2-weighted single-shot fast spin-echo (HASTE) sequence were performed on a 1.5-T scanner (Magnetom Avanto, Siemens, Erlangen, Germany). T2-weighted MR urography was performed in patients with suspected ureteral obstruction. Patients were assigned to three groups: group a, 6 patients with stable allograft function over the previous 4 months; group b, 7 patients with good allograft function who underwent transplantation during the previous 3 weeks; group c, 7 allograft recipients with an acute deterioration of renal function.

RESULTS

Mean cortical perfusion values were 304.8 +/- 34.4, 296.5 +/- 44.1, and 181.9 +/- 53.4 mg/100 ml/min for groups a, b and c, respectively. Reduction in cortical perfusion in group c was statistically significant.

CONCLUSION

Our results indicate that ASL is a promising technique for nonenhanced quantification of cortical perfusion of renal allografts. Further studies are required to determine the clinical value of ASL for monitoring renal allograft recipients.

Marked variation in the definition and diagnosis of delayed graft function: a systematic review

BACKGROUND

The term delayed graft function (DGF) is commonly used to describe the need for dialysis after receiving a kidney transplant. DGF increases morbidity after transplantation, prolongs hospitalization and may lead to premature graft failure. Various definitions of DGF are used in the literature without a uniformly accepted technique to identify DGF.

METHODS

We performed a systematic review of the literature to identify all of the different definitions and diagnostic techniques to identify DGF.

RESULTS

We identified 18 unique definitions for DGF and 10 diagnostic techniques to identify DGF.

CONCLUSIONS

The utilization of heterogeneous clinical criteria to define DGF has certain limitations. It will lead to delayed and sometimes inaccurate diagnosis of DGF. Hence a diagnostic test that identifies DGF reliably and early is necessary. Heterogeneity, in the definitions used for DGF, hinders the evolution of a diagnostic technique to identify DGF, which requires a gold standard definition. We are in need of a new definition that is uniformly accepted across the kidney transplant community. The new definition will be helpful in promoting better communication among transplant professionals and aids in comparing clinical studies of diagnostic techniques to identify DGF and thus may facilitate clinical trials of interventions for the treatment of DGF.

Contrast-enhanced MR angiography (CE-MRA) in the evaluation of vascular complications of renal transplantation

Vascular complications associated with renal transplantation merit urgent investigation since they are often correctable, and timely intervention can help salvage the graft kidney. Contrast-enhanced MR angiography (CE-MRA) is a promising non-invasive technique, uses relatively non-nephrotoxic contrast agents and can rapidly demonstrate the underlying lesion in most instances. In this pictorial review we present the spectrum of abnormalities, as well as the pitfalls of interpretation of CE-MRA, that we encountered in 41 cases where there was clinical suspicion of vascular complications of renal transplantation. We believe that CE-MRA is a valuable, non-invasive screening technique in these cases, and further investigation and management of these patients can be confidently tailored to the results of the CE-MRA study.

Kidney transplantation: evaluation of donors and recipients

MR imaging provides a comprehensive method for noninvasive evaluation of renal donor anatomy. Although multidetector helical CT can provide similar information, MR imaging has the advantage of avoiding exposure to ionizing radiation and potentially nephrotoxic contrast material. These are important considerations in screening a generally healthy donor population. MR imaging also can provide complete evaluation of the kidney after transplantation, where avoidance of potentially nephrotoxic agents and preservation of maximal renal function are critical.

Functional evaluation of normothermic ischemia and reperfusion injury in dog kidney by combining MR diffusion-weighted imaging and Gd-DTPA enhanced first-pass perfusion

PURPOSE

To evaluate functional alterations of renal ischemia and reperfusion injury using MR diffusion-weighted imaging and dynamic perfusion imaging.

MATERIALS AND METHODS

Twelve dogs were randomly divided into four groups. Animal renal ischemia was respectively induced for 30 (group 1), 60 (group 2), 90 (group 3), and 120 (group 4) minutes by left renal artery ligation under anesthesia. Using a 1.5 T MR system, true-FISP, TSE, EPI, and DWI sequences were acquired in five different periods; specifically, pre-ischemia, onset-ischemia, late ischemia, onset-reperfusion, and post-reperfusion. Moreover, a turbo-FLASH sequence (TR/TE/TI/FA = 5.8/3.2/400 msec/10 degrees ) with a temporal resolution of 1.16 seconds was acquired. Signal intensity (SI) was measured in the cortex, outer medulla, and inner medulla of kidney. Apparent diffusion coefficient (ADC) values were calculated, and SI was plotted as a function of time.

RESULTS

In all animals, significant SI changes of the left kidney on T2/T2*WI were detected following ischemia-reperfusion insult compared to corresponding values of the right kidney. Following ligation, the ADC values decreased in all layers of the left kidney. Immediately after the release of ligation, ADC values in both outer and inner medulla of the left kidney remained lower than those of the right kidney in those animals which were induced with renal ischemia for 60, 90, and 120 minutes. In all groups, a uniphasic enhancement pattern was observed in the outer and inner medulla of the left kidney, accompanied by a decrease of the area under the curve.

CONCLUSION

Our results suggest that MR diffusion-weighted imaging and dynamic perfusion imaging are useful in identifying renal dysfunction following normothermic ischemia and reperfusion injury.

In vivo detection of acute rat renal allograft rejection by MRI with USPIO particles

BACKGROUND

Magnetic resonance imaging (MRI) for non-invasively detecting renal rejection was developed by monitoring the accumulation of macrophages labeled with dextran-coated ultrasmall superparamagnetic iron oxide (USPIO) particles at the rat renal allografts during acute rejection.

METHODS

Five groups of male rats with DA-->BN renal allografts and one group with BN-->BN renal isografts were investigated by MRI before, immediately after, and 24 hr after intravenous infusion with different doses of USPIO particles. All infusions were done on post-operative day 4. MRI experiments were carried out in a 4.7-Tesla instrument using a gradient echo sequence.

RESULTS

MR signal intensity (MRSI) of the cortex was found to decrease with higher dosages of USPIO particles. In the absence of USPIO infusion, a decrease in MRSI was seen in the medulla region, presumably due to hemorrhage associated with renal graft rejection, while no significant change was observed in the cortex. The optimal dose of USPIO particles for visualizing rejection-associated changes in our rat kidney model appears to be 6 mg Fe/kg body weight. Iron staining results correlated with the MRSI data, indicating that the signal reduction in the MR images was due to the presence of iron. Immunohistochemical results indicated that USPIO particles were mostly taken up by infiltrating macrophages in the rejecting grafts.

CONCLUSIONS

Our results suggest that MRI with intravenous administration of dextran-coated USPIO particles appears to be a valuable and promising tool that can be used as a non-invasive and sensitive method to detect graft rejection in renal transplantation.

USPIO-enhanced dynamic MRI: evaluation of normal and transplanted rat kidneys

To evaluate first-pass renal perfusion with ultrasmall superparamagnetic iron oxide (USPIO) particles by MRI, 40 normal rats (20 Dark Agouti (DA) rats and 20 Brown Norway (BN) rats) and 16 transplanted rats (12 allografts and four isografts) were studied on day 4 post-transplantation with different USPIO doses (3.0-18.1 mg Fe/kg/body weight). All animals underwent 128 consecutive snapshot fast low-angle shot (FLASH) coronal dynamic studies in 43 s. In the normal rats, a larger maximum signal decrease (MSD) in the cortex and the outer medulla is observed with an increasing dose of USPIO particles (P < 0.01). No significant differences were observed between the right and left kidneys at all doses studied. Higher MSD, time of occurrence of MSD (tMSD), and wash-in slope appear with higher doses of USPIO particles. The dynamic curves for DA rats show similar shapes when compared to those for BN rats. In the transplanted rats, allograft kidneys show lower MSD, longer tMSD, and lower wash-in slope compared to those in the normal kidneys. Isograft kidneys show perfusion patterns similar to those of normal kidneys in the cortex and the outer medulla. Histopathology indicates acute vascular rejection in all allografts and normal kidney architecture in all isografts. The results clearly show good agreement between the renal graft perfusion measurements and histopathological changes associated with rejection. This work also introduces a new signal analysis methodology for the automatic detection of transplanted organ rejection. This method compares the dynamics of the intrarenal signal intensities for native and transplanted kidneys. A quantitative measurement to detect significant differences between these signals was developed, and showed that this technique exhibits good performance in identifying renal rejection.

MRI and ultrasonographic detection of morphologic and hemodynamic changes in chronic renal allograft rejection in the rat

PURPOSE

The purpose of this study is to describe the sonographic, MRI, and histopathologic findings in a rat model of chronic renal allograft rejection.

MATERIALS AND METHODS

Allogeneic renal grafts (male DA kidney into male Lewis rat with unilateral nephrectomy, N = 27) and syngeneic renal grafts (male Lewis kidney into male Lewis rat, N = 19) were examined serially with ultrasound, MRI, and histology.

RESULTS

Nonparametric Spearman rank correlation showed significance between the histologic score and the following parameters: the MRI score (r(s) = 0.91, P < 0.01, N = 46), the ultrasound score (r(s) = 0.9, P < 0.01, N = 46), the power Doppler score (r(s) = 0.86, P < 0.01, N = 46), and the MRI perfusion (r(s) = -0.80, P < 0.01, N = 45). Positive correlations were also found between the MRI volume estimations (graft r(s) = 0.49, P < 0.01, N = 46; native r(s) = 0.59, P < 0.01, N = 46), and the ultrasound volume estimations (graft r(s) = 0.39, P < 0.01, N = 45; native r(s) = 0.64, P < 0.01, N = 46) as well as with actual graft weight.

CONCLUSIONS

This study shows that both MRI and ultrasound can provide complementary, accurate information compared to histology in regard to the alterations in anatomy and hemodynamic changes associated with chronic allograft nephropathy.

The role of magnetic resonance imaging and spectroscopy in transplantation: from animal models to man

Critical success factors in solid organ and vascular transplantation are the assessment of graft status/viability as well as stringent monitoring of transplant recipients, preferentially using noninvasive techniques. This review addresses the application of magnetic resonance imaging (MRI) and spectroscopy (MRS) in the field of transplantation. The first section is devoted to the description of the main MR techniques used for monitoring the status of the graft noninvasively. Subsequently, the role of MRI/MRS in the analysis of the viability of organs for transplantation is discussed. Since chronic rejection remains a major difficulty, development of new therapies is still ongoing. Thus, the third part is devoted to the use of MRI/MRS for monitoring graft rejection in animal models of transplantation. This is followed by a discussion of clinical studies of transplantation involving MRI/MRS. Finally, a general appraisal is made on available imaging techniques for the non-invasive characterization of grafts in situ, highlighting the role of MR methods in the field of transplantation.

Perfusion quantitation in transplanted rat kidney by MRI with arterial spin labeling

The purpose of this study was to determine the feasibility of using quantitative magnetic resonance imaging (MRI) with non-invasive arterial spin labeling to assess perfusion of transplanted kidneys in rats. MRI studies were performed on five groups of rats: normal Fisher 344 rats, Fisher 344 rats that had received a syngeneic kidney transplant either 3 or seven days prior to study, and Fisher 344 rats that had received an allogeneic kidney (ACI rat as the donor) either three or seven days prior to study. The contralateral native kidney remained in place for comparison. Cortical perfusion was quantitated from a slice through the center of each kidney in anesthetized rats at 4.7 Tesla with a fast gradient-echo MRI sequence following the arterial spin labeling. The spin-lattice relaxation time was measured within the cortex, and the cross sectional area of the kidney was also determined within the same MRI plane. Immediately after the perfusion imaging measurement, transplanted kidneys were removed and scored for rejection using the Banff histological criteria. Renal cortical perfusion in normal kidneys was 7.5 +/- 0.8 ml/g/min (N = 12 rats, 24 kidneys). At the third day post-transplantation, that is, before marked acute rejection, the renal cortical perfusion rate was similar in both syngeneic and allogeneic kidneys [3.3 +/- 1.7 (N = 6) and 3.0 +/- 2.4 ml/g/min (N = 6), respectively]. In contrast, at the seventh day post-transplantation, that is, during severe rejection, the renal cortical perfusion rate in allogeneic kidneys was very low (undetectable) compared to the value in syngeneic kidneys [that is, < or = 0.3 (N = 6) versus 5.2 +/- 2.0 ml/g/min (N = 6), respectively]. Moreover, the renal cortical perfusion rate determined by MRI was significantly (P < 0.05, r = -0.82) correlated with histological rejection. We conclude that the quantitative measurement of renal cortical perfusion by MRI with arterial spin-labeling could provide a non-invasive diagnostic method for monitoring the status of renal transplants without requiring the administration of a contrast agent.

Functional magnetic resonance imaging of human renal allografts during the post-transplant period: preliminary observations

Graft dysfunction is a common occurrence during the first weeks following renal transplantation. The current study was designed to evaluate the potential of renal magnetic resonance (MR) perfusion imaging to differentiate acute allograft rejection (AAR) from acute tubular necrosis (ATN) during the post-transplant period. Twenty-three consecutive patients with clinically suspected ATN and/or AAR and eight consecutive control patients (asymptomatic, serum creatinine concentration < 1.5 mg/dL) underwent MR perfusion imaging of the renal allograft within 64 days after transplantation. Histopathology was obtained in all cases with clinical suspicion of ATN or AAR. Sixty sequential fast gradient-recalled-echo MR images were acquired in each patient after intravenous administration of gadolinium-DTPA (0.1 mmol/kg). Histopathology revealed 6 patients with pure AAR, 4 patients with a combination of AAR and ATN, 12 patients with ATN and 1 patient with normal findings. Kidney graft recipients with normal renal function showed a moderate increase in signal intensity (SI) of the renal cortex and medulla after administration of contrast agent followed by an immediate and short decrease in SI of the medulla (biphasic medullary enhancement pattern). The increase in cortical SI of patients with AAR was significantly smaller (61 +/- 4% increase above baseline) than that measured in normal allografts (136 +/- 9% increase above baseline) (p < 0.05) and patients with ATN (129 +/- 3% increase above baseline) (p < .05). Patients with ATN had a slightly delayed and diminished cortical enhancement and an uniphasic and lesser medullary enhancement pattern compared to that observed in normal allografts (p < 0.05). A close correlation (r = 0.72) was found between serum creatinine concentration levels and changes in SI. Thus, MR imaging results and histopathology were in agreement in 22 of 23 patients (96%). MR perfusion imaging of renal allografts can be used to noninvasively differentiate ATN from AAR during the post-transplant period, and may also be helpful in cases were covert AAR is superimposing ATN during a phase of anuria. Patients with ATN can be separated from normals in the majority of cases as reflected by an uniphasic medullary enhancement pattern.