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Review
The Resistive Index in Renal Doppler Sonography:
Where Do We Stand?
Mitchell E. Tublin 1, Ronald O. Bude 2, Joel F. Platt

ray-scale renal sonography is still

routinely performed during the initial evaluation of both native and
transplant renal dysfunction. The results of the
sonography study, however, often do not impact the differential diagnosis or management
of renal disease. Indeed, despite marked improvements in technology, gray-scale renal
sonography has changed little since the 1970s.
Only basic anatomic information is obtained
with the modality: renal length, cortical thickness, and grade of collecting system dilatation
are assessed. Although these findings may help
in evaluating disease chronicity, often the findings of sonography are normal despite severe
renal dysfunction. Moreover, clinicians and radiologists accept that even the increased renal
echogenicity that may be seen with renal failure (medical renal disease) lacks the specificity
and sensitivity to be clinically relevant. Finally,
although collecting system dilatation is reliably
detected, it is often not possible to differentiate
obstructive and nonobstructive pelvicaliectasis
on gray-scale sonography alone. We suspect
that this purely anatomic approach to renal
sonography, coupled with improved yet less
expensive platforms, has resulted in significant
incursions on radiology turf by nephrologists,
internists, and urologists.

A series of articles published during the past

decade indicated the potential of Doppler
sonography for improving the sonographic assessment of renal dysfunction. Changes in intrarenal arterial waveforms were shown to be
associated with urinary obstruction, several
types of intrinsic renal disorders, and renal
vascular disease [136]. The Doppler resistive
index (RI) ([peak systolic velocity end diastolic velocity] / peak systolic velocity) was advanced as a useful parameter for quantifying
the alterations in renal blood flow that may occur with renal disease. Although the results of
this work initially led many laboratories to attempt to incorporate Doppler sonography into
the evaluation of renal dysfunction, discrepant
findings in the literature and discouraging clinical experience prompted most radiologists to
quickly abandon the RI.
In retrospect, the failure of the RI to live up
to its promise as a parameter for measuring
changes in renal status may be due to our often
rudimentary understanding of the pathophysiology of renal disease and how it affects the
Doppler arterial waveform. Nonetheless, we
believe that current skepticism regarding the
role of renal Doppler sonography may be unfortunate, given several recent studies that
have provided a theoretic basis for understand-

ing the abnormal arterial spectra that may be

seen with renal disease. This article may explain why Doppler sonography may not be
helpful in certain situations. Perhaps more important, it may provide a framework for future
investigations of a more refined Doppler assessment of renal pathophysiology. A more sophisticated, clinically relevant approach to
renal imaging, combining anatomy and function, may justify the continued sonographic assessment of renal dysfunction. The purpose of
this article is to discuss the technical requirements of intrarenal Doppler sonography, proposed applications and controversies, recent
research exploring the factors that influence
the Doppler arterial waveform, and prospects
for the future of renal Doppler sonography.

Technique

Most studies describing the potential use of

Doppler sonography for evaluating renal disease have stressed the need for meticulous technique [12, 15]. The highest frequency probe that
gives measurable waveforms should be used,
supplemented by color or power Doppler
sonography as necessary for vessel localization.
Arcuate arteries (at the corticomedullary junction) or interlobar arteries (adjacent to medul-

Received February 27, 2002; accepted after revision September 19, 2002.
1

Department of Radiology, University of Pittsburgh School of Medicine, 200 Lothrop St., Pittsburgh, PA 15213. Address correspondence to M. E. Tublin.

Department of Radiology, University of Michigan Medical School, 130 Catherine Rd., M4101 MS1, Box 0624, Ann Arbor, MI 48109.

AJR 2003;180:885892 0361803X/03/1804885 American Roentgen Ray Society

AJR:180, April 2003

885

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Tublin et al.
lary pyramids) are then insonated using a 2- to
4-mm Doppler gate. Waveforms should be optimized for measurement using the lowest pulse
repetition frequency without aliasing (to maximize waveform size), the highest gain without
obscuring background noise, and the lowest
wall filter (Fig. 1). Three to five reproducible
waveforms from each kidney are obtained, and
RIs from these waveforms are averaged to arrive at mean RI values for each kidney.
Several studies have shown that a normal
mean renal RI is approximately 0.60. The
largest series to date (58 patients) reported a
mean (SD) RI of 0.60 0.01 for subjects
without preexisting renal disease [37]. Three
prior studies also reported normal mean RI
values of 0.64 0.05 (21 patients) [38], 0.58
0.05 (109 kidneys) [8], and 0.62 0.04 (28
patients) [39]. In general, most sonographers
now consider 0.70 to be the upper threshold
of the normal RI in adults [12, 15]. Important
exceptions to this threshold have been reported, however. In children, it is common
for the mean RI to exceed 0.70 through the
first year of life, and a mean RI greater than
0.70 can be seen through at least the first 4
years of life [40, 41]. In elderly patients
without renal insufficiency, the normal RI
can also exceed 0.70 [42]. It is uncertain
whether this is a normal phenomenon, perhaps due to age-related changes in vascular
compliance, or the consequence of small
vessel changes in the kidney due to aging.

Applications
Obstruction

Most literature on renal Doppler sonography has focused on the potential role of Doppler sonography in the evaluation of ureteral
obstruction. The limitations of the gray-scale
examination for potential acute and chronic
obstruction have been recognized for the past
quarter century. The purely anatomic information that is obtained on sonography may be incomplete or misleading: collecting system
dilatation can be caused by conditions that are
not obstructive (residual dilatation from prior
obstruction that has been relieved, pyelonephritis, and reflux). Also, in the acute setting,
obstruction may be present for several hours
before collecting system dilatation occurs.
In the early 1990s, several groups postulated that the pathophysiology of urinary obstruction might be reliably manifested by
changes in arterial Doppler spectra [2, 5, 8, 9,
15, 17, 25]. This application was based on exhaustive animal research that showed a unique
biphasic hemodynamic response to complete
ureteral obstruction. A short period (<2 hr) of
likely prostaglandin-mediated vasodilatation
occurs immediately after obstruction. After
this period, renal blood flow decreases, and renal vascular resistance increases [4347]. Initial studies suggested that this vasoconstriction
response was primarily mechanical, due to increases in collecting system pressures. Recent
research, however, suggests that complex in-

Fig. 1.Normal resistive index in 25-year-old healthy woman. Color Doppler sonogram is used to identify interlobar artery (arrow); waveform is maximized using lowest pulse repetition frequency possible.

886

teractions between several regulatory pathways (reninangiotensin, kallikreinkinin, and

prostaglandinthromboxane) are responsible
for intense, postobstructive renal vasoconstriction [4856].
This vasoconstriction response, however
mediated, seemed to be an ideal phenomenon
to be detected by changes in the RI. In an initial
series from researchers at the University of
Michigan, RIs from 21 hydronephrotic kidneys
were obtained before nephrostomy. The mean
RI in 14 kidneys with confirmed obstruction
(0.77 0.04) was significantly higher than the
mean RI from seven kidneys with nonobstructive pelvicaliectasis (0.64 0.04). Moreover,
RI values returned to normal after nephrostomy
[8]. These encouraging results were essentially
duplicated in a larger study of 229 kidneys. In
this study, a discriminatory RI threshold of 0.70
was used; the sensitivity and specificity of the
Doppler diagnosis of obstruction were 92%
and 88%, respectively. Moreover, the accuracy
of the Doppler diagnosis of obstruction increased when the RI of the potentially obstructed kidney was compared with that of the
unaffected contralateral kidney (Fig. 2). An RI
difference greater than 0.10 between kidneys
was seen only with true obstructive pelvicaliectasis [9]. After these encouraging results, series were published indicating the potential of
Doppler sonography to differentiate renal
transplant obstructive and nonobstructive pelvicaliectasis [13] and to determine ureteral stent
patency [16].
Although these and several other encouraging reports [2, 5, 25, 33, 36, 57] have prompted
many centers to add RI analysis to the sonographic evaluation of collecting system dilatation, anecdotal experience, follow-up clinical
trials, and animal studies have dampened enthusiasm for the clinical impact of Doppler
sonography [5865]. The utility of Doppler
sonography in the evaluation of partial ureteral
obstruction was found to be particularly limited. In a series published by Chen et al. [60],
for example, the sensitivity of Doppler sonography for the diagnosis of obstruction was reported to be only 52%. Although the results of
the examination were often positive with highgrade obstruction, most patients with partial
obstruction had normal RIs. This failure of
Doppler sonography to reliably detect lowgrade obstruction was subsequently confirmed
in pig and rabbit models [64, 65]. Several
groups have shown that the sensitivity of Doppler sonography for the detection of partial obstruction may be improved by performing the
study after forced diuresis (diuretic Doppler

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Resistive Index in Renal Doppler Sonography

sonography) [6674]. This technique has not
yet been embraced by either the general radiology or the urology community, although recent experimental work has provided a
theoretic justification for the use of diuretic
Doppler sonography in the evaluation of obstructive uropathy.
The potential role of Doppler sonography
in the evaluation of renal colic has been particularly controversial. In two initial series,
either an RI greater than 0.70 or a difference
of greater than 0.060.10 in mean RI values
between kidneys was found to be highly specific and sensitive for acute obstruction [17,
25]. Perhaps more important, several cases of
obstruction were identified before the development of collecting system dilatation. Unfortunately, to our knowledge, these results
were not duplicated in later series. In a study
performed at the University of Pittsburgh of
32 patients with suspected ureteral obstruction, for example, the sensitivity and specificity of the Doppler assessment of obstruction
were only 44% and 82%, respectively [58].
Deyoe et al. [59] published nearly identical
results. Several reasons for these discrepant
findings were suggested in a spirited commentary published in Radiology [75, 76].
These reasons included the absence of patients with partial obstruction in initial promising studies, the potential vasodilatory
effects of nonsteroidal medications typically
used for the treatment of pain associated with
urinary calculi, the uncertain effect of hydration on renal blood flow (and the RI), and the
potential of the iodinated contrast material
used for excretory urography (the gold standard in all studies) to induce intense vasoconstriction. Many of these confounding factors
were subsequently addressed in follow-up
studies [66, 77, 78].
Unfortunately, instead of fostering investigation into the role of Doppler sonography in
the acute setting, this debate contributed to
skepticism over the utility of the RI. Moreover, the recent almost universal acceptance
of unenhanced CT as a gold standard for the
identification of ureteral calculi has markedly decreased any incentive to perform
sonography in the acute setting, except perhaps in the evaluation of the pregnant patient [79, 80].
Nonobstructive Renal Disease

The lack of specificity of the gray-scale examination in evaluating intrinsic renal disease
has been frustrating to nephrologists and radiologists for decades. Although renal size, corti-

AJR:180, April 2003

Fig. 2.30-year-old man with acute left flank pain.

A, Sonogram shows unobstructed right kidney and corresponding normal resistive index.
B, Sonogram shows obstructed left kidney. Note mild collecting system dilatation, elevated left RI, and marked
difference in RIs (0.12) between kidneys. (Reprinted with permission from [58])

cal thickness, and echogenicity may be helpful

in assessing disease chronicity, these findings
typically do not aid in the differential diagnosis or management of renal disease.
The potential of Doppler sonography to
serve as a useful adjunct for the gray-scale assessment of renal disease was advanced in a
series of articles published by the group from
the University of Michigan. In the initial work
performed by Platt et al. [10], renal biopsy results of 41 patients were correlated with RI
analysis. Those patients with isolated glomerular disease had normal RI values (mean, 0.58),
whereas subjects with vascular or interstitial
disease had markedly elevated RI values
(means, 0.87 and 0.75, respectively). Unfortunately, these encouraging results were not reproduced in similarly designed studies
performed by Mostbeck et al. [81] and more
recently by McDermott et al. [82]. Moreover,
there was little correlation between the degree
of renal dysfunction (assessed by serum creatinine values) and the RI.
Although Doppler sonography clearly
does not substitute for renal biopsy, several
studies have suggested that Doppler sonography might aid in the management of established renal disease. In a series published by
Patriquin et al. [7], for the example, Doppler
sonography could predict renal recovery from

hemolytic uremic syndrome before clinical

improvement. Similarly, the RI was thought
to correlate well with renal involvement in
patients with progressive systemic sclerosis
[28]. The ability of Doppler sonography to
identify latent hepatorenal syndrome before
liver transplantation was shown by the University of Michigan group [14]. Those same
researchers reported that Doppler sonography
was useful in predicting the outcome of patients with lupus nephritis: in a prospective
series of 34 patients with various degrees of
nephritis, an elevated RI value was shown to
be a predictor of poor renal outcome, even in
patients with normal baseline renal function
[20]. Doppler sonography was also suggested
as a useful tool for evaluating nonobstructive
acute renal failure; an RI greater than 0.07
was found to be a reliable discriminator between acute tubular necrosis and prerenal
failure, although a theoretic framework (and
supporting histologic findings) to explain this
finding was lacking [11]. Finally, the RI has
been advocated as a useful marker of diabetic
nephropathy [83, 84], although other studies
have suggested that Doppler sonography offers little beyond serum creatinine levels and
creatinine clearance rates in patients with
early diabetic nephropathy and normal renal
function [19, 31, 35, 85].

887

Tublin et al.

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Doppler Sonography of Renal Transplant

Dysfunction

A swing from initial enthusiasm to skepticism

also occurred over a series of articles exploring
the role of Doppler sonography in the evaluation
of transplant dysfunction [1, 3, 4, 2224, 8690].
An elevated RI was initially considered a finding
specific for rejection [1, 3, 22, 23]. Multiple researchers have since documented the lack of specificity of an elevated RI [8690]. In a series
published by Perrella et al. [87], for example, the
sensitivity and specificity of Doppler sonography
for the diagnosis of rejection were 43% and 67%,
respectively, when a threshold RI of 0.90 was applied. Because of these discouraging results, most
physicians consider an elevated RI to be a nonspecific marker of transplant dysfunction. Although
RI analysis is not helpful in differentiating the typical causes of transplant dysfunction (acute tubular necrosis, rejection, and immunosuppression
toxicity), it is still useful for potentially identifying
vascular complications associated with transplantation. Although intrarenal Doppler sonography
has failed as a reliable screening examination for
transplant renal artery stenosis, identification of a
tardusparvus waveform from an intrarenal artery
should prompt even more diligent color and duplex Doppler evaluation of the renal artery anastomosis to exclude arterial stenosis [6]. Focal highvelocity, low-impedance intrarenal arterial flow
might suggest an arteriovenous fistula. Finally, renal vein thrombosis may be present when diastolic flow is reversed and no renal venous flow is
detected [91].
Theory of RI

As suggested previously, the failure of the

RI to become a meaningful parameter for evaluating kidney physiology and function may be
due to our often rudimentary understanding of
renal disease. Furthermore, Doppler sonographic analysis of renal artery waveforms was
empirically applied to disease characterization
before a full understanding of the factors that
affect the arterial waveform (e.g., vascular
compliance, vascular resistance, and heart
rate) was obtained. Thus, this empiric use of
Doppler sonography gave less than satisfactory results. For example, it was almost universally accepted in the early Doppler literature
that the RI varied directly with changes in renal vascular resistance. In many reports, the
terms resistive index and renal vascular resistance are used interchangeably, although
the relationship between these factors and
other potentially confounding variables has,
generally, not been considered.

888

Systolic

Adjustable
height
Diastolic

Function
generator
Solenoid

Pressure
transducer
O2
CO2 Gas

P
F
Data acquisition
computer

Flow
meter

Water
heated to
body temp

Adjustable
height
Stirrer

Pump

Heater
Artery

Ureter

Vein
Kidney

Fig. 3.Diagram of ex vivo pulsatile perfusion system. Perfusion pressures (systole and diastole) are adjusted
by changing heights of reservoirs, and pulse rate is controlled by function generator. Flow (F) and pressure (P)
are measured instantaneously upstream from renal artery using in-line probes. Doppler spectra are simultaneously obtained from perfused kidney using commercially available ultrasound platform. Temp = temperature.
(Reprinted with permission from [94])

A series of in vitro experiments recently

performed at the University of Michigan has
convincingly shown the importance of vascular compliance in RI analysis [92]. (Compliance is the rate of change of volume of a
vessel as a function of pressure. Anyone who
has observed a pulsating artery whose diameter expands in systole and contracts in diastole has seen the visual manifestation of the
effect of compliance.) In vitro experiments
were performed to assess the impact of
changes in vascular resistance and compliance on the RI. The RI was dependent on
vascular compliance and resistance, becoming less and less dependent on resistance as
compliance decreased, and being completely
independent of vascular resistance when
compliance was zero. In another in vitro
study performed by the same group, the RI
was shown to decrease with increases in the
cross-sectional area of the distal arterial bed;
this effect was independent of compliance
and vascular resistance.
Ex vivo results, similar to in vitro results,
were obtained in a series of experiments performed at Albany Medical College [93]. Rabbit
kidneys were perfused ex vivo using a pulsatile
perfusion system (Fig. 3). Renal vascular resistance, systole, diastole, pulse pressure, and
pulse rate were controlled and monitored while

the RI was simultaneously measured. A linear

relationship was seen between the RI and pharmacologically induced changes in renal vascular resistance. However, the RI increased only
with marked, likely nonphysiologic increases in
renal vascular resistance. Those changes in the
RI that were seen with intense vasoconstriction
were only marginally greater than RI measurement variability. The RI was markedly affected
by changes in driving pulse pressures, however.
A linear relationship was shown between the
pulse pressure index (systolic pressure diastolic pressure / systolic pressure) and the RI.
In a follow-up series of experiments, the Albany group attempted to indirectly explore the
effect of changes in vascular distensibility on
the RI ex vivo [94]. Isolated rabbit kidneys were
subjected to pulsatile perfusion while the renal
pelvis was pressurized via the ureter. The authors hypothesized that resultant increases in renal interstitial pressure would decrease arterial
distensibility and that these effects would be
most marked during diastole. Arterial distensibility was indirectly assessed by analyzing
changes in vascular conductance (flow / pressure). Graded increases in renal pelvic pressures
resulted in increased renal vascular resistance,
decreased mean conductance, an increased conductance index (systolic conductance diastolic
conductance / systolic conductance) and an in-

AJR:180, April 2003

Resistive Index in Renal Doppler Sonography

0 mm Hg
Ureteral pressure
Systole

Systole

Diastole

Interstitial
pressure
Diastole

Intraarterial
pressure

m Hg

Hg

60 m

0 mm

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60 mm Hg
Ureteral pressure

Fig. 4.Diagram shows how ureteral pressure affects mean, systolic, and diastolic cross-sectional areas of renal arterioles. Area of compliant vessels is determined by transmural pressure (intraarterial pressure interstitial pressure). Interstitial pressure is almost zero in absence of ureteral pressure (left half of diagram). During
diastole, cross-sectional area of vessel is relatively large (B), and some additional distention occurs during systole (A). High ureteral pressures increase interstitial pressure (right half of diagram). In this setting, arteriole is
almost occluded during diastole because transmural pressure is so low (D), but significant distention still occurs
during systole (C). Although mean cross-sectional area is markedly smaller with high ureteral pressures (mean
conductance of C and D, A and B), relative distention that occurs during systole is greater (conductance of A >
B, but C >>D). These cyclic changes in cross-sectional area are underlying cause for parallel changes in total
renal conductance (flow / pressure). (Reprinted with permission from [94])

0 mm Hg

creased RI. The results indicated the importance

of the interaction among vascular distensibility,
resistance, and pulsatile flow in RI analysis
(Figs. 4 and 5). Many of these findings were
replicated in a study performed by Claudon et
al. [95], in which changes in pig renal blood
flow during acute urinary obstruction were assessed using contrast-enhanced harmonic
sonography. Overall, these trials have convincingly shown that disease phenomena that affect
vascular distensibility, such as renal artery interstitial fibrosis and vascular stiffening, might
substantially affect the RI.
This body of experimental work may
help explain the disappointing results obtained using the RI to evaluate ureteral obstruction. The high false-negative rate of the
technique may, in some cases, be due to
low-grade, extremely early obstruction or
forniceal rupture. In these settings and with
severe long-standing obstruction, arterial
distensibility would be marginally affected
because interstitial pressures are relatively
normal. The increased reliability of Doppler
sonography when a furosemide challenge is
used might also suggest the impact of
acutely elevated interstitial pressures on renal blood flow and the RI.
The complex interaction between renal vascular resistance and compliance might also help
explain the failure of Doppler sonography to
consistently differentiate types of intrinsic renal

60 mm Hg

Systole

Diastole

Fig. 5.Diagram shows how ureteral pressure affects systolic and diastolic blood flow in larger renal arteries typically insonated during clinical renal Doppler studies.
Each section of figure shows Doppler gate in conduit (segmental or arcuate) artery, which branches into smaller compliant vessels downstream. Length of arrow in Doppler
gate represents velocity of blood flow. As shown in Figure 4, changes in ureteral pressure (0 mm Hg in A and B; 60 mm Hg in C and D) significantly affect arteriolar crosssectional areas and thus total blood flow volume. In less compliant, larger conduit arteries, these changes in blood flow are manifested as cyclic changes in blood velocity.
Thus, relative increase in velocity that occurs at systole (measured using resistive index) is greater when ureteral pressure is elevated (velocity in A > B, but C >> D). (Reprinted with permission from [94])

AJR:180, April 2003

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Tublin et al.
disease. One might speculate that early reports
of elevated RIs with vascularinterstitial disease
(and not glomerulopathies) were primarily due
to the decreased tissue and vascular compliance
associated with these types of renal diseases
(and not only associated with increased renal
vascular resistance). Later discouraging reports
might be due to differing patient populations
and mixed renal diseases; a single isolated RI
may not be useful in the differential diagnosis of
intrinsic renal disease because of mixed histology and differing effects on vascular compliance and resistance. On the other hand, the
impact of vascular compliance on the RI may
help to explain recent encouraging studies exploring the utility of Doppler sonography in the
assessment of end-organ damage in patients
with hypertension and arteriosclerosis. In several recent studies, an elevated RI was found to
correlate with left ventricular hypertrophy and
carotid intimal thickening [9698].
Conclusion

We do not mean to imply that Doppler

sonography currently has no role in the evaluation of renal disorders. The Doppler arterial
waveform is the product of the interaction of a
number of factors, sometimes in a complicated
way. Once these factors are better understood,
and if they can be taken into account, correctly
understood Doppler sonography may be a useful clinical tool to evaluate renal dysfunction.
A more sophisticated functional approach may
allow radiologists to maintain a preeminent
role in the imaging assessment of renal disease. Further studies into this topic are suggested and strongly encouraged.
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