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Evaluation of Doppler ultrasound for renal transplant evaluationfor renal transplant evaluation
ARRS meeting2011‐05‐03
F Edward Boas, Terry Desser and Aya KamayaTerry Desser, and Aya Kamaya
Stanford Hospital
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Disclosure of commercial interestDisclosure of commercial interest
Neither I nor my immediate family membersNeither I nor my immediate family members have a financial relationship with a commercial organization that may have acommercial organization that may have a direct or indirect interest in the content.
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DiagnosesDiagnoses
Diagnosis Number of patients1. Normal, with creatinine ≤ 1.5 72. Delayed graft function post‐operatively 63 Acute rejection 83. Acute rejection 84. Chronic rejection, transplant
glomerulopathy, or drug toxicity, i i 1 5
5
creatinine > 1.55. Hydronephrosis 56. Renal vein thrombosis 27. Other 14Total 47
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Resistive index = (V –V i )/VResistive index (Vmax Vmin)/Vmax
yow
velocit
Fl
V V iTime
Vmax Vmin
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Resistive indexResistive indexSensitivity 38% for acute rejectionSpecificity 63%
30%
35%
40%Normal (0.71 ± 0.11)
Acute rejection (0.77 ± 0.11)
Other
20%
25%
30%
10%
15% Acute rejectionDelayed graft functionRenal vein thrombosis
0%
5%
<0.7 0.70 – 0.79 0.80 – 0.89 0.90 – 0.99 ≥1<0.7 0.70 0.79 0.80 0.89 0.90 0.99 ≥1Resistive index
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Mid renal artery velocity waveformMid renal artery velocity waveform
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Velocity waveformsVelocity waveforms
30
15
20
25
w (m
l/s)
— Normal— Acute rejection
5
10
15
artery flow
‐10
‐5
00 0.2 0.4 0.6 0.8 1Re
nal
10Fraction of cardiac cycle
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Velocity waveformsVelocity waveforms
30
15
20
25
w (m
l/s)
— Normal— Acute rejection— Delayed graft function— Chronic rejection
5
10
15
artery flow
Chronic rejection— Hydronephrosis— Renal vein thrombosis— Other
‐10
‐5
00 0.2 0.4 0.6 0.8 1Re
nal
10Fraction of cardiac cycle
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Velocity waveforms (average)Velocity waveforms (average)20
15
ml/s) Normal
5
10
tery flow
(m
Acute rejection
00 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
in re
nal art
‐10
‐5Mai
Renal vein thrombosis
Fraction of cardiac cycle
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Velocity waveforms (Average ± stdev)Velocity waveforms (Average ± stdev)20
Thick lines: average
15
ml/s) Normal
Thick lines: averageThin lines: one standard deviation
5
10
tery flow
(m
Acute rejection
00 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
in re
nal art
‐10
‐5Mai
Renal vein thrombosis
Fraction of cardiac cycle
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Windkessel modelWindkessel model
lSystole
Pulsatile pump Continuous capillary flow
Image credits: Piotr Michał Jaworski (kidney) and User ZooFari on Wikipedia (heart). Creative Commons Attribution‐Share Alike 3.0 Unported license.
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Windkessel modelWindkessel model
lSystole
Pulsatile pump Continuous capillary flow
Image credits: Piotr Michał Jaworski (kidney) and User ZooFari on Wikipedia (heart). Creative Commons Attribution‐Share Alike 3.0 Unported license.
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Windkessel modelWindkessel model
lSystole
Pulsatile pump Continuous capillary flow
Image credits: Piotr Michał Jaworski (kidney) and User ZooFari on Wikipedia (heart). Creative Commons Attribution‐Share Alike 3.0 Unported license.
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Windkessel modelWindkessel model
lDiastole
Pulsatile pump Continuous capillary flow
Image credits: Piotr Michał Jaworski (kidney) and User ZooFari on Wikipedia (heart). Creative Commons Attribution‐Share Alike 3.0 Unported license.
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Windkessel modelWindkessel model
lDiastole
Pulsatile pump Continuous capillary flow
Image credits: Piotr Michał Jaworski (kidney) and User ZooFari on Wikipedia (heart). Creative Commons Attribution‐Share Alike 3.0 Unported license.
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Windkessel modelWindkessel model
lDiastole
Pulsatile pump Continuous capillary flow
Image credits: Piotr Michał Jaworski (kidney) and User ZooFari on Wikipedia (heart). Creative Commons Attribution‐Share Alike 3.0 Unported license.
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3‐element Windkessel model3 element Windkessel model
R1 Pre‐glomerular resistance (renal artery)
C Vascular compliance
R2 Post‐glomerular resistance (renal vein)
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3‐element Windkessel model3 element Windkessel model
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NormalNormal
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High R1High R1
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NormalNormal
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High R2High R2
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NormalNormal
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Low CLow C
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3‐element Windkessel model250 7
150
200
24
5
6
C
50
100
R 2
1
2
3
C
00 10 20 30
R1
00 10 20 30
R17
4
5
6 NormalAcute rejectionDelayed graft functionChronic rejection
1
2
3
C Chronic rejectionHydronephrosisRenal vein thrombosisOther
00 50 100 150 200 250
R2
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3‐element Windkessel model250 7
150
200
24
5
6
C
Renal vein thrombosis
50
100
R 2
1
2
3
C
00 10 20 30
R1
00 10 20 30
R17
4
5
6 NormalAcute rejectionDelayed graft functionChronic rejection
1
2
3
C Chronic rejectionHydronephrosisRenal vein thrombosisOther
00 50 100 150 200 250
R2
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Doppler ultrasoundDoppler ultrasound
Acute rejection can’t be diagnosed using:Acute rejection can t be diagnosed using:
• resistive index (intra‐renal)
l l i• pre‐glomerular resistance
• post‐glomerular resistance
• vascular compliance
• the shape of the velocity waveform (mid renalthe shape of the velocity waveform (mid renal artery)
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ConclusionsConclusions
• Doppler ultrasound of kidney transplants hasDoppler ultrasound of kidney transplants has limited value in diagnosing acute rejection.
• Resistive index > 0 9 is seen in acute rejection• Resistive index > 0.9 is seen in acute rejection, delayed graft function, and renal vein thrombosisthrombosis.
• The 3‐element Windkessel model can be used d i l i dto determine vascular resistance and
compliance.
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Additional slidesAdditional slides
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3‐element Windkessel model3 element Windkessel model
Resistive index is increased with:Resistive index is increased with:
• Increased R2 (post‐glomerular resistance)
d ( l l i )• Decreased R1 (pre‐glomerular resistance)
• Increased C (vascular compliance)
• Increased pulse pressure
• Increased heart rateIncreased heart rate
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Principal component analysisPrincipal component analysis
Average waveform Principal components
12 0.25 Flow
Average waveform Principal components
6
8
10
w (m
l/s)
0.05
0.1
0.15
0.2
ml/s)
Biphasic pulsatilityTriphasic pulsatility
2
4
6
Flow
‐0.15
‐0.1
‐0.05
00 0.2 0.4 0.6 0.8 1
Flow
(m0
0 0.2 0.4 0.6 0.8 1
Fraction of cardiac cycle‐0.25
‐0.2
Fraction of cardiac cycle
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Principal component analysis
30
40
50
60
70
lsatility
0
5
10
15
20
ulsatility
‐10
0
10
20
‐50 0 50 100
Biph
asic pu
‐20
‐15
‐10
‐5‐50 0 50 100
riph
asic pu
‐30
‐20B
Flow
‐30
‐25Tr
Flow
20
0
5
10
15
20
ulsatility Normal
Acute rejectionDelayed graft functionChronic rejection
25
‐20
‐15
‐10
‐5‐50 0 50 100
Tripha
sic pu Chronic rejection
HydronephrosisRenal vein thrombosisOther
‐30
‐25T
Biphasic pulsatility