radiological assessment of the kidney in patients with hematuria

Jeremy McKay, HMS III

Gillian Lieberman, MD

Radiological Assessment of Radiological Assessment of the Kidney in Patients with the Kidney in Patients with

HematuriaHematuria

Jeremy L. McKay, Harvard Medical Jeremy L. McKay, Harvard Medical School Year IIISchool Year III

Gillian Lieberman, MDGillian Lieberman, MD

March 2005



HematuriaHematuria

Signs and SymptomsSigns and Symptoms–– Microscopic or gross Microscopic or gross hematuriahematuria–– Abdominal painAbdominal pain–– FeverFever–– PolyuriaPolyuria, , dysuriadysuria–– Flank painFlank pain

HematuriaHematuria is commonis common–– 2.5% of men ages 282.5% of men ages 28--57 tested positive for 57 tested positive for

hemeheme–– 5.4% men ages 185.4% men ages 18--5454



HematuriaHematuria cont.cont.

Retrospective Study of 100 patients with Retrospective Study of 100 patients with hematuriahematuria–– Most Common Causes:Most Common Causes:

41.8% 41.8% NeoplasiaNeoplasia–– 19% BPH19% BPH–– 9% Bladder9% Bladder–– 6% Kidney6% Kidney–– 6% Prostate6% Prostate

26.6% Infection26.6% Infection13.6% 13.6% NephrolithiasisNephrolithiasis3.6% Congenital Abnormalities3.6% Congenital Abnormalities2% Trauma2% Trauma12% No identifiable cause12% No identifiable cause



Renal Causes of Renal Causes of hematuriahematuriaVasculitisVasculitis–– HenochHenoch--SchonleinSchonlein purpurapurpura, , periarteritisperiarteritis nodosanodosa, Wegener , Wegener

granulomatosisgranulomatosis

GlomerularGlomerular diseasedisease–– PostinfectiousPostinfectious nephritis, nephritis, IgAIgA nephropathy, Lupus, nephropathy, Lupus, AlportAlport, thin , thin

basement membrane disease, Nailbasement membrane disease, Nail--patella syndrome, patella syndrome, FabryFabry diseasedisease

TubulointerstitialTubulointerstitial diseasedisease–– Polycystic kidney disease, Polycystic kidney disease, nephrolithiasisnephrolithiasis, analgesic nephropathy, , analgesic nephropathy,

reflux nephropathy, tumors, infectionreflux nephropathy, tumors, infection

Renal MassesRenal Masses–– Vascular, Vascular, neoplasticneoplastic, congenital, congenital

VascularVascular–– AV malformations, renal artery disease, renal vein thrombosisAV malformations, renal artery disease, renal vein thrombosis



Diagnostic Imaging MethodsDiagnostic Imaging MethodsUSUS–– Best to exclude urinary obstructionBest to exclude urinary obstruction–– Can diagnose Can diagnose hydronephrosishydronephrosis and it’s causeand it’s cause–– Should be performed in all patients presenting Should be performed in all patients presenting

with renal failure of unknown etiologywith renal failure of unknown etiology–– Chronic Chronic pyelonephritispyelonephritis with no response to with no response to

therapytherapy–– Doppler US to evaluate renal vascular flow Doppler US to evaluate renal vascular flow



Diagnostic Imaging MethodsDiagnostic Imaging Methods

CT ScanCT Scan–– Often compliments findings with Often compliments findings with

ultrasonographyultrasonography–– NonNon--contrast: Gold standard for radiologic contrast: Gold standard for radiologic

diagnosis of renal stonesdiagnosis of renal stones–– Used to evaluate and stage renal cell Used to evaluate and stage renal cell

carcinomacarcinoma–– Used to diagnose renal vein thrombosisUsed to diagnose renal vein thrombosis




MRIMRI–– Gold standard for Gold standard for DxDx of renal vein thrombosis of renal vein thrombosis

along with renal along with renal venographyvenography and CTand CT–– MRA playing an increasing role in evaluating MRA playing an increasing role in evaluating

patients with patients with renovascularrenovascular hypertension hypertension decreasing need for renal angiographydecreasing need for renal angiography

–– For patients with dye allergiesFor patients with dye allergies




Plain Film of the AbdomenPlain Film of the Abdomen

–– Good for patients complaining of symptoms Good for patients complaining of symptoms consistent with consistent with nephrolithiasisnephrolithiasis..

–– Will miss small and radiolucent stonesWill miss small and radiolucent stones–– Not commonly performed on patients with Not commonly performed on patients with

renal disease renal disease




Intravenous Intravenous pyelogrampyelogram–– Previously the principal radiologic technique Previously the principal radiologic technique

used for patients with possible renal diseaseused for patients with possible renal disease–– High sensitivity and specificity for detection of High sensitivity and specificity for detection of

stones and degree of obstructionstones and degree of obstruction–– Structural disorders: Chronic Structural disorders: Chronic pyelopyelo, , medullarymedullary

sponge kidney, papillary necrosissponge kidney, papillary necrosis




Renal Renal ArteriographyArteriography–– Used less frequently due to less invasive CT Used less frequently due to less invasive CT

and MRIand MRI–– Useful in Useful in DxDx of of polyarteritispolyarteritis nodosanodosa–– Used in preoperative mapping of vasculatureUsed in preoperative mapping of vasculature

Renal Renal VenographyVenography–– Useful for Useful for DxDx of renal vein thrombosisof renal vein thrombosis




Radionuclide studiesRadionuclide studies–– Early detection of Early detection of vesicoureteralvesicoureteral reflux and reflux and

scarring; More sensitive than IVP in detecting scarring; More sensitive than IVP in detecting renal scarsrenal scars

Voiding Voiding cystourethrogramcystourethrogram–– VesicoureteralVesicoureteral refluxreflux

Retrograde/Retrograde/AnterogradeAnterograde PyelographyPyelography–– Relieve urinary tract obstructionRelieve urinary tract obstruction–– Supplanted by US and CTSupplanted by US and CT



Diagnostic Imaging MethodsDiagnostic Imaging MethodsCT CT UrographyUrography–– Combines unenhanced, Combines unenhanced, nephrogenicnephrogenic--phase, phase,

and excretory phase imagingand excretory phase imagingUnenhancedUnenhanced-- detects renal calculidetects renal calculiNephrogenicNephrogenic phase phase –– renal renal parenchymalparenchymalabnormalities (esp. masses)abnormalities (esp. masses)Excretory phase Excretory phase –– urothelialurothelial diseasedisease

–– Becoming standard diagnostic methodBecoming standard diagnostic method



Renal MassesRenal Masses

Renal masses frequently cause Renal masses frequently cause hematuriahematuriaCharacterization of the mass is essentialCharacterization of the mass is essential–– Simple cyst, complex cyst, or solid massSimple cyst, complex cyst, or solid mass

BosniakBosniak Classification SystemClassification System–– I and II I and II –– benignbenign–– IIIIII--IV IV –– possibly malignant, warranting possibly malignant, warranting

surgerysurgery

CTU, CT, US, MRCTU, CT, US, MR



Spiral CT Evaluation of the Kidney (in: Spiral CT: Principles, Techniques and Clinical Applications. Fishman, Jeffrey, eds. 1998)

Patient 1: Simple Cysts on CT

Contrast Enhanced

Without Contrast




Patient 2: Wilms Tumor

Enlarged non- functioning left renal mass




Patient 3: Renal Cell Carcinoma on contrast enhanced CT




Patient 4: Stage III Renal Cell Carcinoma involving left renal vein



Renal InfectionsRenal Infections

PyelonephritisPyelonephritis–– Acute, chronic, reflux nephropathyAcute, chronic, reflux nephropathy–– Flank pain, fever, urgencyFlank pain, fever, urgency–– Radiologic imaging:Radiologic imaging:

IVPIVPCTUCTUUSUS



BIDMC Radiology Dept.

Patient 5: Pyelonephritis on CT




BIDMC Radiology Dept.



.med.wayne.edu/ diagRadiology/TF/GU/GU09.html




Renal CalculiRenal Calculi

NephrolithiasisNephrolithiasis–– Common cause of Common cause of hematuriahematuria–– 12% will develop kidney stones12% will develop kidney stones–– Plain film not as sensitive as unenhanced CTPlain film not as sensitive as unenhanced CT–– CT (unenhanced) for renal calculiCT (unenhanced) for renal calculi–– US also useful for detecting renal calculi as US also useful for detecting renal calculi as

well as well as hydronephrosishydronephrosis–– “Colicky pain”“Colicky pain”



urologyassociates.com/ stonepuz.html

Patient 8: Right Hydronephrosis on IVP



Spiral CT Evaluation of the Kidney (in: Spiral CT: Principles, Techniques and Clinical Applications. Fishman, Jeffrey, eds. 1998

Patient 9: Left Renal Pelvis Obstruction on CT



Congenital AnomaliesCongenital Anomalies

Some congenital anomalies in the urinary Some congenital anomalies in the urinary tract can cause tract can cause hematuriahematuria

Well visualized with CT, US, IVP, and MR Well visualized with CT, US, IVP, and MR imagingimaging




Patient 10: Adult Polycystic Renal Disease



Patient 11Patient 11

63 year63 year--old maleold male–– Presented to the ED with gross Presented to the ED with gross hematuriahematuria, ,

flank pain, and fever lasting for two daysflank pain, and fever lasting for two days–– PMH: hypercholesterolemia, HTN, PE, IVC PMH: hypercholesterolemia, HTN, PE, IVC

filter, depression, filter, depression, s/ps/p cholechole–– Meds: ASA 81, Coumadin 2.5, Lipitor 80, Meds: ASA 81, Coumadin 2.5, Lipitor 80,

MetoprololMetoprolol 50, Viagra 50, 50, Viagra 50, WellbutrinWellbutrin 5050–– Exam: 97.5 207lbs 110/70 97% 64Exam: 97.5 207lbs 110/70 97% 64

Exam relatively normalExam relatively normalLabs: UA: gross Labs: UA: gross hematuriahematuria. INR = 8. INR = 8



10/04 CT Abd. BIDMC Radiology Dept. PACS

Patient 11: Baseline CTU w/o contrast 10/04



Patient 11: Current CT abd w/o contrast

3/05 CTU Abd. BIDMC Radiology Dept. PACS

•Bilateral fat stranding

•Both kidneys appear larger


Gillian Lieberman, MD Patient 11: CT abd w/o contrast


•Dilated renal pelvis



Patient 11: CTU contrast phase


•Dilated renal pelvis



Patient 11: CTU reformatted




Patient 11Patient 11Findings:Findings:–– New New perinephricperinephric and and periureteralperiureteral fat strandingfat stranding–– Bilateral proximal and mid Bilateral proximal and mid ureteralureteral wall thickeningwall thickening–– Mild bilateral Mild bilateral hydronephrosishydronephrosis–– Both enhance symmetrically, no calculiBoth enhance symmetrically, no calculi

Impression:Impression:–– Concerning for transitional cell carcinomaConcerning for transitional cell carcinoma–– Further evaluation with retrograde Further evaluation with retrograde ureterogramureterogram was was

recommended after antibiotic treatmentrecommended after antibiotic treatment–– Likely Diagnosis: Acute Likely Diagnosis: Acute PyelonephritisPyelonephritis with possible with possible

underlying transitional cell carcinomaunderlying transitional cell carcinoma



SummarySummary

HematuriaHematuria is commonis common–– Most Common Causes: Most Common Causes: NeoplasiaNeoplasia, infection, , infection,

stones. stones. –– Renal causes of Renal causes of hematuriahematuria

VasculitisVasculitis, , GlomerularGlomerular disease, disease, TubulointerstitialTubulointerstitialdisease, Renal masses, Vasculardisease, Renal masses, Vascular

–– US, CT (U), MR(U), IVP are great techniques US, CT (U), MR(U), IVP are great techniques for imagingfor imaging

–– CT CT UrographyUrography: Combines unenhanced, : Combines unenhanced, nephrogenicnephrogenic--phase, and excretory phase phase, and excretory phase

Becoming modality of choiceBecoming modality of choice



Works CitedWorks Cited

RameshRamesh and Kimmel. and Kimmel. HematuriaHematuria: An Algorithmic : An Algorithmic ApporachApporach to Finding the to Finding the Cause. Cleveland Clinic Journal of Medicine 2002; 69: 870Cause. Cleveland Clinic Journal of Medicine 2002; 69: 870--884884FroomFroom, Gross, , Gross, FroomFroom, , CaineCaine, , MargaliotMargaliot, , BenbassatBenbassat. Factors Associated with . Factors Associated with MicrohematuriaMicrohematuria in asymptomatic young men. in asymptomatic young men. ClinClin ChemChem 1986; 32:20131986; 32:2013--20152015RithieRithie CD, Bevan EA, Collier SJ. Importance of occult CD, Bevan EA, Collier SJ. Importance of occult haematuriahaematuria found at found at screening. BMJ 1986; 292:681screening. BMJ 1986; 292:681--683683GillatGillat DA, O’Reilly PH. DA, O’Reilly PH. HematuriaHematuria Analyzed; A Prospective Study. J R Soc Analyzed; A Prospective Study. J R Soc Med 1987; 80559Med 1987; 80559--562562Carter WC, Rous SN. Gross Carter WC, Rous SN. Gross HematuriaHematuria in 110 Adult Urological Hospital in 110 Adult Urological Hospital Patients. Urology 1981; 18:342Patients. Urology 1981; 18:342--344344http://http://www.ctisus.com/ctprotocolswww.ctisus.com/ctprotocols//American College of Radiology (ACR), Expert Panel on Urologic ImAmerican College of Radiology (ACR), Expert Panel on Urologic Imaging. aging. Radiologic investigation of patients with Radiologic investigation of patients with hematuriahematuria. Reston (VA): American . Reston (VA): American College of Radiology (ACR); 2001College of Radiology (ACR); 2001JoffeJoffe, , ServaesServaes, , OkonOkon, Horowitz: Multi, Horowitz: Multi--Detector Row CT Detector Row CT UrographyUrography in the in the Evaluation of Evaluation of HematuriaHematuria. Radio Graphics 2003; 23:1441. Radio Graphics 2003; 23:1441--14561456



AcknowledgementsAcknowledgementsPeter Peter RosalRosal, MD, MDDaniel Daniel CornfeldCornfeld, MD, MDGillian Lieberman, MDGillian Lieberman, MDPamela Pamela LepkowskiLepkowskiLarry Barbaras, WebmasterLarry Barbaras, Webmaster

radiological assessment of the kidney in patients with hematuria

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