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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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ACR Appropriateness Criteria® Renovascular Hypertension. J Am Coll Radiol 2017; 14:S540-S549. [DOI: 10.1016/j.jacr.2017.08.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 11/24/2022]
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Trautmann A, Roebuck DJ, McLaren CA, Brennan E, Marks SD, Tullus K. Non-invasive imaging cannot replace formal angiography in the diagnosis of renovascular hypertension. Pediatr Nephrol 2017; 32:495-502. [PMID: 27747454 DOI: 10.1007/s00467-016-3501-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 08/24/2016] [Accepted: 08/25/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Renovascular disease (RVD) is found in about 10 % of secondary childhood hypertension. Digital subtraction angiography (DSA) is the gold standard to diagnose RVD. Non-invasive imaging methods like Doppler ultrasound (US), magnetic resonance angiography (MRA), and computed tomography angiography (CTA) are increasingly used. Our aim was to evaluate the role and accuracy of US, MRA, and CTA compared to DSA in diagnosing RVD in children. PATIENTS AND METHODS A retrospective review of 127 children with suspected renovascular hypertension was performed in children referred to Great Ormond Street Hospital between 2006 and 2014 due to clinical suspicion of renovascular hypertension and/or findings on US and/or MRA or CTA. RESULTS Ninety-nine of 127 children (78 %) were diagnosed with renovascular disease and 80 were treated with percutaneous transluminal angioplasty during the same procedure. The median age at presentation was 5.6 (range, 2.5-10.6) years. Thirty-six children had unilateral renal artery stenosis in major extraparenchymal vessels, 47 bilateral stenosis and 16 intrarenal small vessel disease. US had a sensitivity of 63 % and specificity of 95 %. MRA and CTA were performed in 39 and 34 children, respectively. CTA sensitivity was slightly higher than that of MRA, 88 vs. 80 %, and specificity 81 vs. 63 %. CONCLUSIONS The sensitivity of MRA and CTA is still too low to reliably rule out renovascular disease in children with a strong suspicion of this diagnosis. DSA remains the gold standard to diagnose renovascular hypertension and is recommended when clinical and laboratory criteria are highly suggestive of renovascular disease even with normal radiological investigations from non-invasive methods.
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Affiliation(s)
- Agnes Trautmann
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
- Department of Pediatric Nephrology, University Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Derek J Roebuck
- Department of Radiology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Clare A McLaren
- Department of Radiology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Eileen Brennan
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Stephen D Marks
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Kjell Tullus
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK.
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Schäberle W, Leyerer L, Schierling W, Pfister K. Ultrasound diagnostics of renal artery stenosis: Stenosis criteria, CEUS and recurrent in-stent stenosis. GEFASSCHIRURGIE 2015; 21:4-13. [PMID: 27034579 PMCID: PMC4767855 DOI: 10.1007/s00772-015-0060-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background and purpose As a non-invasive, side effect-free and cost-effective method, ultrasonography represents the method of choice for the diagnosis of renal artery stenosis. Four different criteria in total, including two direct criteria in peak systolic velocity (PSV) and renal aortic ratio (RAR) and two indirect criteria in resistance index (RI) and acceleration time (AT) for the measurement of relevant renal artery stenosis are described, each demonstrating highly variable accuracy in studies. Furthermore, there is controversy over the degree beyond which stenosis becomes therapeutically relevant and which ultrasound PSV is diagnostically relevant in terms of stenosis grading. Material and methods This article gives a critical review based on a selective literature search on measurement methodology and the validity of ultrasound in renal artery stenosis. A critical evaluation of methods and a presentation of measurement principles to establish the most precise measurement method possible compared with the gold standard angiography, as well as an evaluation of the importance of computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Results and conclusions The PSV provides high sensitivity and specificity as a direct measurement method in stenosis detection and grading. Most studies found sensitivities and specificities of 85–90 % for > 50 % stenosis at a PSV > 180–200 cm/s in ROC curve analysis. Other methods, such as the ratio of the PSV in the aorta to the PSV in the renal artery (RAR) or indirect criteria, such as side to side differences in RI (dRI) or AT can be additionally used to improve accuracy. Contrast-enhanced ultrasound improves accuracy by means of echo contrast enhancement. Although in the past only high-grade stenosis was considered relevant for treatment, a drop in pressure of > 20 mmHg in > 50 % stenosis (PSV 180 cm/s) is classified as relevant for increased renin secretion. Stenosis in fibromuscular dysplasia can be reliably graded according to the continuity equation. Although the available studies on the grading of in-stent restenosis are the subject of controversy, there is a tendency to assume higher cut-off values for PSV and RAR. Whilst MRA and CTA demonstrate an accuracy of > 90 %, this is at the cost of possible side effects for patients, particularly in the case of pre-existing renal parenchymal damage. Additional online material This article includes two additional video sequences on visualizing renal artery stenosis. This supplemental material can be found under: dx.doi.org/10.1007/s00772-015-0060-3
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Affiliation(s)
- W Schäberle
- Department of Visceral, Vascular, Thorax and Pediatric Surgery, "Klinik am Eichert", Eichertstr. 3, 73035 Göppingen, Germany
| | - L Leyerer
- Department of Visceral, Vascular, Thorax and Pediatric Surgery, "Klinik am Eichert", Eichertstr. 3, 73035 Göppingen, Germany
| | - W Schierling
- Vascular and Endovascular Surgery, Regensburg University Hospital, Regensburg, Germany
| | - K Pfister
- Vascular and Endovascular Surgery, Regensburg University Hospital, Regensburg, Germany
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Chhadia S, Cohn RA, Vural G, Donaldson JS. Renal Doppler evaluation in the child with hypertension: a reasonable screening discriminator? Pediatr Radiol 2013; 43:1549-56. [PMID: 23860636 DOI: 10.1007/s00247-013-2741-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 05/28/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Hypertension is diagnosed in 1-5% of children, and 5-10% of those hypertensive children have renovascular disease. The gold standard for a diagnosis of renal artery stenosis is arteriography, and Doppler ultrasound (Doppler US) continues to be advocated as a useful screening test. OBJECTIVE The purpose of this study was to determine the utility of Doppler US in children as a screening tool and to better define clinical features of children in whom arteriography should be performed. MATERIALS AND METHODS This retrospective study evaluated the imaging and clinical parameters for all children who had a renal US with Doppler followed by a diagnostic arteriogram for the evaluation of hypertension during a 12-year period at a tertiary children's hospital. Sixty-two children were included. We evaluated each child's clinical parameters and placed each child into one of three categories of hypertension: mild, moderate or severe. RESULTS Eleven of 17 kidneys with proven renal artery stenosis were detected with Doppler US (sensitivity 64%). Six children with renal artery stenosis were missed by Doppler US, four of whom had segmental artery lesions. Of the children with positive renal artery stenosis on arteriography, all but three (79%) were classified as having moderate to severe hypertension. CONCLUSION Doppler US is a useful screening examination when evaluating children with hypertension, detecting renal artery stenosis in most affected children. The clinical risk classifications are helpful in guiding which children should proceed with arteriography regardless of the Doppler US results.
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Affiliation(s)
- Sumit Chhadia
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
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AbuRahma AF, Yacoub M. Renal imaging: duplex ultrasound, computed tomography angiography, magnetic resonance angiography, and angiography. Semin Vasc Surg 2013; 26:134-43. [DOI: 10.1053/j.semvascsurg.2014.06.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Judd E, Lockhart ME, Rizk DV. Renovascular hypertension associated with pseudoaneurysm following blunt trauma. Am J Kidney Dis 2013; 62:839-43. [PMID: 23518197 DOI: 10.1053/j.ajkd.2012.12.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 12/18/2012] [Indexed: 11/11/2022]
Abstract
We present the case of a 21-year-old man who developed a renal artery pseudoaneurysm following a 7-foot fall onto his back. He initially presented with gross hematuria, left flank pain, and back pain. He was observed in the hospital for 3 days and discharged. One week later, he was readmitted with headache, nausea, vomiting, seizure activity, and hypertension. Contrast-enhanced computed tomography of the abdomen showed a left renal artery pseudoaneurysm with associated arterial narrowing and delayed ipsilateral renal enhancement. He underwent percutaneous stent-graft placement with resolution of the pseudoaneurysm. He was free of complications and normotensive off antihypertensive medications after 36 months of follow-up. Renal artery pseudoaneurysms are rare and under-recognized complications of blunt abdominal or back trauma that can cause hypertension. Imaging modalities in renovascular hypertension have focused on detecting renal artery stenosis from atherosclerotic disease or fibromuscular dysplasia, with little attention given to renal artery pseudoaneurysms. In addition, first-line treatment for renal artery pseudoaneurysms historically has consisted of angioembolization, yet percutaneous stent-graft placement has emerged as an attractive alternative to preserve vessel patency. We discuss the role of imaging in renovascular hypertension with a focus on renal artery pseudoaneurysms and their prevalence, diagnosis, and treatment.
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Affiliation(s)
- Eric Judd
- University of Alabama at Birmingham, Birmingham, AL.
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Critical analysis of renal duplex ultrasound parameters in detecting significant renal artery stenosis. J Vasc Surg 2012; 56:1052-9, 1060.e1; discussion 1059-60. [DOI: 10.1016/j.jvs.2012.03.036] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 03/09/2012] [Accepted: 03/10/2012] [Indexed: 11/24/2022]
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McArthur C, Baxter GM. Current and potential renal applications of contrast-enhanced ultrasound. Clin Radiol 2012; 67:909-22. [PMID: 22464920 DOI: 10.1016/j.crad.2012.01.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 01/14/2012] [Accepted: 01/25/2012] [Indexed: 12/18/2022]
Abstract
The combination of microbubble technology and complementary ultrasound techniques has resulted in the development of contrast-enhanced ultrasound (CEUS) and, although initial clinical applications largely focussed on the liver, these are now becoming more diverse. With regard to the kidney, it is a safe, well-tolerated, and reproducible technique, and in selected cases, can obviate the need for computed tomography or magnetic resonance imaging. A clear advantage is the absence of nephrotoxicity. With respect to the current and potential renal applications, it is a useful technique in the evaluation of pseudotumours, acute pyelonephritis, renal tumours, cystic lesions, vascular insults, and renal transplantation. It may also be of value for monitoring the kidney following anti-angiogenic treatment or nephron-sparing interventional techniques for renal tumours. Assessment of microvascular perfusion using time-intensity curves is also likely to have further far-reaching applications in the kidney as well as other organs.
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Affiliation(s)
- C McArthur
- Department of Radiology, Western Infirmary, Glasgow, UK
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