Review

Ultrasonography of the Kidney: A Pictorial Review

Kristoffer Lindskov Hansen *, Michael Bachmann Nielsen † and Caroline Ewertsen †
Received: 4 November 2015; Accepted: 17 December 2015; Published: 23 December 2015
Academic Editor: Zhen Cheng

Department of Radiology, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100-DK, Denmark;

mbn@dadlnet.dk (M.B.N.); caroline.ewertsen@dadlnet.dk (C.E.)
* Correspondence: lindskov@gmail.com; Tel.: +45-3545-3545; Fax: +45-3545-2058
† These authors contributed equally to this work.

Abstract: Ultrasonography of the kidneys is essential in the diagnosis and management of

kidney-related diseases. The kidneys are easily examined, and most pathological changes in the
kidneys are distinguishable with ultrasound. In this pictorial review, the most common findings in
renal ultrasound are highlighted.

Keywords: renal ultrasound; pictorial review; practical guide

1. Introduction
Renal ultrasound (US) is a common examination, which has been performed for decades [1].
Using B-mode imaging, assessment of renal anatomy is easily performed, and US is often used as image
guidance for renal interventions. Furthermore, novel applications in renal US have been introduced
with contrast-enhanced ultrasound (CEUS), elastography and fusion imaging. In this pictorial review,
we will highlight the most common findings in renal US.

2. Examination Technique
The ultrasonic renal exam does not require any preparation of the patient and is usually performed
with the patient in the supine position. The kidneys are examined in longitudinal and transverse
scan planes with the transducer placed in the flanks. When insonation of the kidney is obscured
by intestinal air, the supine scan position is combined with the lateral decubitus position with the
transducer moved dorsally. Preferably, the exam is initiated in the longitudinal scan plane, parallel to
the long diameter of the kidney, as the kidney is easier to distinguish [2].
In the adult patient, a curved array transducer with center frequencies of 3–6 MHz is used, while
the pediatric patient should be examined with a linear array transducer with higher center frequencies.
Artifacts of the lowest ribs always shadow the upper poles of the kidneys. However, the whole
kidney can be examined during either normal respiration or breath hold, as the kidney will follow the
diaphragm and change position accordingly [2].

3. Findings in the Normal Kidney

In the longitudinal scan plane, the kidney has the characteristic oval bean-shape. The right
kidney is often found more caudally and is slimmer than the left kidney, which may have a so-called
dromedary hump due to its proximity to the spleen [3]. The kidney is surrounded by a capsule
separating the kidney from the echogenic perirenal fat, which is seen as a thin linear structure [3].
The kidney is divided into parenchyma and renal sinus. The renal sinus is hyperechoic and
is composed of calyces, the renal pelvis, fat and the major intrarenal vessels. In the normal kidney,
the urinary collecting system in the renal sinus is not visible, but it creates a heteroechoic appearance
with the interposed fat and vessels. The parenchyma is more hypoechoic and homogenous and is

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divided into the outermost cortex and the innermost and slightly less echogenic medullary pyramids [3].
divided into the outermost cortex and the innermost and slightly less echogenic medullary pyramids [3]. 
divided into the outermost cortex and the innermost and slightly less echogenic medullary pyramids [3]. 
Between the pyramids are the cortical infoldings, called columns of Bertin (Figure 1). In the pediatric
Between the pyramids are the cortical infoldings, called columns of Bertin (Figure 1). In the pediatric 
Between the pyramids are the cortical infoldings, called columns of Bertin (Figure 1). In the pediatric 
patient, it 
patient,  it is 
is easier 
easier to 
to differentiate
differentiate  the
the  hypoechoic medullar pyramids 
hypoechoic  medullar  pyramids from 
from the 
the more 
more echogenic
echogenic 
patient, 
peripheralit  is 
zoneeasier 
of to 
the differentiate 
cortex in the the  hypoechoic 
parenchyma rim, medullar 
as well as pyramids 
the from 
columns of the 
Bertinmore  echogenic 
(Figure 2) [2,4].
peripheral zone of the cortex in the parenchyma rim, as well as the columns of Bertin (Figure 2) [2,4]. 
peripheral zone of the cortex in the parenchyma rim, as well as the columns of Bertin (Figure 2) [2,4]. 

 
 
Figure 1. Normal adult kidney. Measurement of kidney length on the US image is illustrated by ‘+’ 
Figure 1. Normal adult kidney. Measurement of kidney length on the US image is illustrated by ‘+’ and
Figure 1. Normal adult kidney. Measurement of kidney length on the US image is illustrated by ‘+’ 
and a dashed line. * Column of Bertin; ** pyramid; *** cortex; **** sinus. 
a dashed line. * Column of Bertin; ** pyramid; *** cortex; **** sinus.
and a dashed line. * Column of Bertin; ** pyramid; *** cortex; **** sinus. 

 
 
Figure 2. Normal pediatric kidney. * Column of Bertin; ** pyramid; *** cortex; **** sinus. 
Figure 2. Normal pediatric kidney. * Column of Bertin; ** pyramid; *** cortex; **** sinus. 
Figure 2. Normal pediatric kidney. * Column of Bertin; ** pyramid; *** cortex; **** sinus.
The  length  of  the  adult  kidney  is  normally  10–12  cm,  and  the  right  kidney  is  often  slightly 
The  length  of  the  adult  kidney  is  normally  10–12  cm,  and  the  right  kidney  is  often  slightly 
longer than the left kidney [3,5]. The adult kidney size is variable due to the correlation with body 
The length of the adult kidney is normally 10–12 cm, and the right kidney is often slightly longer
longer than the left kidney [3,5]. The adult kidney size is variable due to the correlation with body 
height and age [3,5–7]; however, normograms for pediatric kidney size are available [7–9]. 
than the left kidney [3,5]. The adult kidney size is variable due to the correlation with body height and
height and age [3,5–7]; however, normograms for pediatric kidney size are available [7–9]. 
Cortical thickness should be estimated from the base of the pyramid and is generally 7–10 mm. 
age [3,5–7]; however, normograms for pediatric kidney size are available [7–9].
Cortical thickness should be estimated from the base of the pyramid and is generally 7–10 mm. 
If  the  pyramids  are  difficult 
Cortical thickness shouldto bedifferentiate, 
estimated from the the
parenchymal 
base of thethickness  can  is
pyramid and be  measured  instead 
mm.  
If  the  pyramids  are  difficult  to  differentiate,  the  parenchymal  thickness  can  be generally
measured 
and should be 15–20 mm (Figure 3) [6]. The echogenicity of the cortex decreases with age and is less 
7–10
instead   
If the pyramids are difficult to differentiate, the parenchymal thickness can be measured instead
and should be 15–20 mm (Figure 3) [6]. The echogenicity of the cortex decreases with age and is less 
echogenic than or equal to the liver and spleen at the same depth in individuals older than six months 
and should be 15–20 mm (Figure 3) [6]. The echogenicity of the cortex decreases with age and is
echogenic than or equal to the liver and spleen at the same depth in individuals older than six months 
[3]. In neonates and children up to six months of age, the cortex is more echogenic than the liver and 
less echogenic than or equal to the liver and spleen at the same depth in individuals older than
[3]. In neonates and children up to six months of age, the cortex is more echogenic than the liver and 
spleen when compared at the same depth [10]. 
six months [3]. In neonates and children up to six months of age, the cortex is more echogenic than the
spleen when compared at the same depth [10]. 
liver and spleen when compared at the same depth [10].

 
 
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Figure 3. Measures of the kidney. L = length. P = parenchymal thickness. C = cortical thickness. 
Figure 3. Measures of the kidney. L = length. P = parenchymal thickness. C = cortical thickness. 
Figure 3. Measures of the kidney. L = length. P = parenchymal thickness. C = cortical thickness.
Doppler examination of the kidney is widely used, and the vessels are easily depicted by the 
Doppler examination of the kidney is widely used, and the vessels are easily depicted by the 
color Doppler
Doppler  examination
technique  in of the kidney
order  is widelyperfusion. 
to  evaluate  used, and the vessels spectral 
Applying  are easilyDoppler 
depictedto 
color  Doppler  technique  in  order  to  evaluate  perfusion.  Applying  spectral  Doppler  to  the  renal 
bythe 
the renal 
color
Doppler
artery  technique
and  selected ininterlobular 
order to evaluate perfusion.
arteries,  Applying spectralresistive 
Dopplerindex 
to theand 
renal artery and
artery  and  selected  interlobular  arteries, peak 
peak systolic  velocities, 
systolic  velocities,  resistive  index  acceleration 
and  acceleration 
selected interlobular arteries, peak systolic velocities, resistive index and acceleration
curves can be estimated (Figure 4) [11], e.g., peak systolic velocity of the renal artery above 180 cm/s  curves can be
curves can be estimated (Figure 4) [11], e.g., peak systolic velocity of the renal artery above 180 cm/s 
estimated
is a predictor of renal artery stenosis of more than 60%, and the resistive index, which is a calculated  of
(Figure 4) [11], e.g., peak systolic velocity of the renal artery above 180 cm/s
is a predictor of renal artery stenosis of more than 60%, and the resistive index, which is a calculated  is a predictor
renal from 
from  artery stenosis
peak peak 
systolic  of more
systolic 
and  and 
end than
end  60%, velocity, 
and
systolic 
systolic  the resistive
velocity,  index,
above  0.70 
above  0.70  is which
is  is a of 
indicative 
indicative calculated
abnormal 
of  from
abnormal  peak systolic
renovascular 
renovascular 
and end systolic velocity,
resistance [7]. 
resistance [7].  above 0.70 is indicative of abnormal renovascular resistance [7].

 
Figure  4.  Doppler  ultrasound  (US)  of  a  normal  adult  kidney  with  the  estimation  of  the  systolic 
 
velocity (Vs), the diastolic velocity (Vd), acceleration time (AoAT), systolic acceleration (Ao Accel) 
and resistive index (RI). Red and blue colors in the color box represent flow towards and away from 
Figure 
Figure 4. Doppler
4. Doppler ultrasound
ultrasound  (US) 
(US) of  a  normal 
ofspecrogram 
a normal adult 
adult kidneykidney  with 
with the the  estimation 
estimation of the of  the  velocity
systolic systolic 
the  transducer,  respectively.  The  below  the  B‐mode  image  shows  flow  velocity  (m/s) 
velocity (Vs), the diastolic velocity (Vd), acceleration time (AoAT), systolic acceleration (Ao Accel) 
(Vs), the diastolic velocity (Vd), acceleration time (AoAT), systolic acceleration (Ao Accel) and resistive
against time (s) obtained within the range gate. The small flash icons on the spectrogram represent 
and resistive index (RI). Red and blue colors in the color box represent flow towards and away from 
indexinitiation of the flow measurement. 
(RI). Red and blue colors in the color box represent flow towards and away from the transducer,
the  transducer, 
respectively. respectively. 
The specrogramThe  specrogram 
below below 
the B-mode the shows
image B‐mode  image 
flow shows 
velocity flow against
(m/s) velocity  (m/s) 
time (s)
against time (s) obtained within the range gate. The small flash icons on the spectrogram represent 
obtained within the range gate. The small flash icons on the spectrogram represent initiation of the
 
initiation of the flow measurement. 
flow measurement.

 
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4. Cystic Renal Masses
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Masses are seen as a distortion of the normal renal architecture. Most renal masses are simple
cortical Masses are seen as a distortion of the normal renal architecture. Most renal masses are simple 
cysts with a round appearance and a smooth thin capsule encompassing anechoic fluid.
4. Cystic Renal Masses 
cortical cysts with a round appearance and a smooth thin capsule encompassing anechoic fluid. The 
The incidence increases with age, as at least 50% of people above the age of 50 have a simple cyst in
Masses are seen as a distortion of the normal renal architecture. Most renal masses are simple 
incidence  increases  with  age,  as  at  least  50%  of  people  above  the  age  of  50  have  a  simple  cyst  in   
one of the kidneys [12]. Cysts cause posterior enhancement as a consequence of reduced attenuation
cortical cysts with a round appearance and a smooth thin capsule encompassing anechoic fluid. The 
one of the kidneys [12]. Cysts cause posterior enhancement as a consequence of reduced attenuation 
of theincidence 
ultrasound within theage, 
increases  with  cystas 
fluid (Figure
at  least  50% 5). The simple
of  people  above cyst is a of 
the  age  benign lesion,
50  have  which
a  simple  does
cyst  in    not
of the ultrasound within the cyst fluid (Figure 5). The simple cyst is a benign lesion, which does not 
require further evaluation [13].
one of the kidneys [12]. Cysts cause posterior enhancement as a consequence of reduced attenuation 
require further evaluation [13]. 
of the ultrasound within the cyst fluid (Figure 5). The simple cyst is a benign lesion, which does not 
require further evaluation [13]. 

 
Figure 5. Simple cyst with posterior enhancement in an adult kidney. Measurement of kidney length 
Figure 5. Simple cyst with posterior enhancement in an adult kidney. Measurement  of kidney length
on the US image is illustrated by ‘+’ and a dashed line. 
on the US image is illustrated by ‘+’ and a dashed line.
Figure 5. Simple cyst with posterior enhancement in an adult kidney. Measurement of kidney length 
on the US image is illustrated by ‘+’ and a dashed line. 
Complex  cysts  can  have  membranes  dividing  the  fluid‐filled  center  with  internal  echoes, 
Complex cysts can have membranes dividing the fluid-filled center with internal echoes,
calcifications or irregular thickened walls. The complex cyst can be further evaluated with Doppler US, 
Complex 
calcifications cysts  can 
or irregular have  membranes 
thickened walls. The dividing 
complex the 
cystfluid‐filled  center 
can be further with  internal 
evaluated echoes,  US,
with Doppler
and for Bosniak classification and follow‐up of complex cysts, either contrast‐enhanced ultrasound 
calcifications or irregular thickened walls. The complex cyst can be further evaluated with Doppler US, 
and for Bosniak classification and follow-up of complex cysts, either contrast-enhanced ultrasound
(CEUS) or contrast‐enhanced computed tomography (CT) are used (Figure 6) [14,15]. The Bosniak 
and for Bosniak classification and follow‐up of complex cysts, either contrast‐enhanced ultrasound 
(CEUS) or contrast-enhanced
classification  computed
is  divided  into  tomography
four  groups  (CT)
going  from  are used (Figure
I,  corresponding  to  a 6) [14,15].
simple  The
cyst,  to  Bosniak
IV, 
(CEUS) or contrast‐enhanced computed tomography (CT) are used (Figure 6) [14,15]. The Bosniak 
corresponding to a cyst with solid parts and an 85%–100% risk of malignancy [13,16]. 
classification is divided into four groups going from I, corresponding to a simple cyst, to IV,
classification  is  divided  into  four  groups  going  from  I,  corresponding  to  a  simple  cyst,  to  IV, 
corresponding to a cyst with solid parts and an 85%–100% risk of malignancy [13,16].
corresponding to a cyst with solid parts and an 85%–100% risk of malignancy [13,16]. 

 
Figure 6. Complex cyst with thickened walls and membranes in the lower pole of an adult kidney. 
 
Measurements  of  kidney  length  and  the  complex  cyst  on  the  US  image  are  illustrated  by  ‘+’  and 
Figure 6. Complex cyst with thickened walls and membranes in the lower pole of an adult kidney. 
dashed lines. 
Figure 6. Complex cyst with thickened walls and membranes in the lower pole of an adult kidney.
Measurements  of  kidney  length  and  the  complex  cyst  on  the  US  image  are  illustrated  by  ‘+’  and 
Measurements of kidney length and the complex cyst on the US image are illustrated by ‘+’ and
dashed lines.   
dashed lines.
 
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In  polycystic  kidney  disease,  multiple  cysts  of  varying  size  in  close  contact  with  each 
Diagnostics 2016, 6, 0000  2 of 18 other   

are seen filling virtually the entire renal region. In advanced stages of this disease, the kidneys are 
In polycystic kidney disease, multiple cysts of varying size in close contact with each other are
In  polycystic  kidney  disease,  multiple  cysts  of  varying  size  in  close  contact  with  each  other   
enlarged with a lack of corticomedullary differentiation (Figure 7) [17]. 
seen filling virtually the entire renal region. In advanced stages of this disease, the kidneys are enlarged
are seen filling virtually the entire renal region. In advanced stages of this disease, the kidneys are 
with enlarged with a lack of corticomedullary differentiation (Figure 7) [17]. 
a lack of corticomedullary differentiation (Figure 7) [17].

   
Figure 7. Advanced polycystic kidney disease with multiple cysts. 
Figure 7. Advanced polycystic kidney disease with multiple cysts. 
Figure 7. Advanced polycystic kidney disease with multiple cysts.
5. Solid Renal Masses 
5. Solid Renal Masses 
5. Solid Renal Masses
A  solid  renal  mass  appears  in  the  US  exam  with  internal  echoes,  without  the  well‐defined, 
A 
A solid renal
solid
smooth  renal 
walls  mass 
mass
seen  in  appears 
appears
cysts,  in with 
in the
often  the  US 
US exam exam 
with
Doppler  with  internal 
internal
signal,  and echoes, echoes, 
without
is  frequently  without  the has 
well‐defined, 
the well-defined,
malignant  or  smooth
a  high 
smooth  walls  seen  in  cysts,  often  with  Doppler  signal,  and  is  frequently  malignant 
malignant potential [4]. The most common malignant renal parenchymal tumor is renal cell carcinoma 
walls seen in cysts, often with Doppler signal, and is frequently malignant or has a high malignant or  has  a  high 
(RCC), which accounts for 86% of the malignancies in the kidney [2]. RCCs are typically isoechoic 
malignant potential [4]. The most common malignant renal parenchymal tumor is renal cell carcinoma 
potential [4]. The most common malignant renal parenchymal tumor is renal cell carcinoma (RCC),
which and peripherally located in the parenchyma, but can be both hypo‐ and hyper‐echoic and are found 
(RCC), which accounts for 86% of the malignancies in the kidney [2]. RCCs are typically isoechoic 
accounts for 86% of the malignancies in the kidney [2]. RCCs are typically isoechoic and
centrally in medulla or sinus. The lesions can be multifocal and have cystic elements due to necrosis, 
and peripherally located in the parenchyma, but can be both hypo‐ and hyper‐echoic and are found 
peripherally located in the parenchyma, but can be both hypo- and hyper-echoic and are found
calcifications and be multifocal (Figures 8 and 9) [2]. RCC is associated with von Hippel–Lindau disease, 
centrally in medulla or sinus. The lesions can be multifocal and have cystic elements due to necrosis, 
centrally in medulla or sinus. The lesions can be multifocal and have cystic elements due to necrosis,
and with tuberous sclerosis, and US has been recommended as a tool for assessment and follow‐up 
calcifications and be multifocal (Figures 8 and 9) [2]. RCC is associated with von Hippel–Lindau disease, 
calcifications and be multifocal (Figures 8 and 9) [2]. RCC is associated with von Hippel–Lindau
of renal masses in these patients [18]. 
and with tuberous sclerosis, and US has been recommended as a tool for assessment and follow‐up 
disease, and with tuberous sclerosis, and US has been recommended as a tool for assessment and
of renal masses in these patients [18]. 
follow-up of renal masses in these patients [18].

 
Figure 8. Cortical solid mass, which later was shown to be renal cell carcinoma. Measurement of the 
solid mass on the US image is illustrated by ‘+’ and a dashed line. 
 
Figure 8. Cortical solid mass, which later was shown to be renal cell carcinoma. Measurement of the
Figure 8. Cortical solid mass, which later was shown to be renal cell carcinoma. Measurement of the 
solid mass on the US image is illustrated by ‘+’ and  a dashed line.
solid mass on the US image is illustrated by ‘+’ and a dashed line. 

 
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Figure 
Figure  9. 
Figure 9.  Renal 
9. Renalcell 
Renal  cellcarcinoma 
cell  carcinomawith 
carcinoma  withboth 
with  both cystic 
both  cystic and 
cystic  and solid 
and  solid components 
solid  components located 
components  located in 
located  in the 
in  the cortex. 
the  cortex.
cortex. 
Measurement of tumor on the US image is illustrated by ‘+’ and a dashed line.. 
Measurement of tumor on the US image is illustrated by ‘+’ and a dashed line.
Measurement of tumor on the US image is illustrated by ‘+’ and a dashed line.. 

However, US is not the primary modality for the evaluation of solid tumors in the kidney, and CT
However, US is not the primary modality for the evaluation of solid tumors in the kidney, and 
However, US is not the primary modality for the evaluation of solid tumors in the kidney, and 
is the first choice modality [19]. Nevertheless, hemorrhagic cysts can resemble RCC on CT, but they
CT is the first choice modality [19]. Nevertheless, hemorrhagic cysts can resemble RCC on CT, but 
CT is the first choice modality [19]. Nevertheless, hemorrhagic cysts can resemble RCC on CT, but 
are easily distinguished with US using Doppler [19]. In RCCs, Doppler US often shows vessels with
they are easily distinguished with US using Doppler [19]. In RCCs, Doppler US often shows vessels 
they are easily distinguished with US using Doppler [19]. In RCCs, Doppler US often shows vessels 
high velocities caused by neovascularization and arteriovenous shunting.
with high velocities caused by neovascularization and arteriovenous shunting. 
with high velocities caused by neovascularization and arteriovenous shunting. 
Some
Some RCCs
Some  RCCs are
RCCs  hypovascular
are 
are  hypovascular 
hypovascular and notnot 
and 
and  distinguishable
not  withwith 
distinguishable 
distinguishable  Doppler
with  US. Therefore,
Doppler 
Doppler  US.  renal tumors
US.  Therefore, 
Therefore,  renal 
renal 
without a Doppler signal, which are not obvious simple cysts on US and CT, should
tumors without a Doppler signal, which are not obvious simple cysts on US and CT, should be further be
tumors without a Doppler signal, which are not obvious simple cysts on US and CT, should be further  further
investigated with CEUS, as CEUS is more sensitive than both Doppler US and CT for the detection of
investigated with CEUS, as CEUS is more sensitive than both Doppler US and CT for the detection of 
investigated with CEUS, as CEUS is more sensitive than both Doppler US and CT for the detection of 
hypovascular tumors [20].
hypovascular tumors [20]. 
hypovascular tumors [20]. 
Other malignant tumors in the kidney are transitional cell carcinoma and squamous cell carcinoma,
Other malignant tumors in the kidney are transitional cell carcinoma and squamous cell carcinoma, 
Other malignant tumors in the kidney are transitional cell carcinoma and squamous cell carcinoma, 
which arise from the urothelium and are found the renal sinus, as well as adenocarcinoma, lymphoma
which arise from the urothelium and are found the renal sinus, as well as adenocarcinoma, lymphoma 
which arise from the urothelium and are found the renal sinus, as well as adenocarcinoma, lymphoma 
and metastases, which can be found anywhere in the kidney (Figure 10) [2,4].
and metastases, which can be found anywhere in the kidney (Figure 10) [2,4]. 
and metastases, which can be found anywhere in the kidney (Figure 10) [2,4]. 

  
Figure 10. Solid tumor in the renal sinus seen as a hypoechoic mass, later found to be lymphoma. The 
Figure 10. Solid tumor in the renal sinus seen as a hypoechoic mass, later found to be lymphoma. The 
Figure 10. Solid tumor in the renal sinus seen as a hypoechoic mass, later found to be lymphoma.
‘1’ and ‘2’ on the US image are reference points used for CT fusion (not shown). 
‘1’ and ‘2’ on the US image are reference points used for CT fusion (not shown). 
The ‘1’ and ‘2’ on the US image are reference points used for CT fusion (not shown).

  
Diagnostics 2016, 6, 2 7 of 18

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Benign solid tumors  of the kidney are oncocytoma and angiomyofibroma. Oncocytoma
Diagnostics 2016, 6, 0000  2 of 18  has

a varyingBenign  solid  appearance,

ultrasonic tumors  of  the but kidney 
may are  oncocytoma 
have a central and  angiomyofibroma. 
scar or calcificationOncocytoma 
as a hallmarkhas   [21].
Benign 
a  varying  solid  tumors 
ultrasonic  of  the  kidney 
appearance,  are have 
but  may  oncocytoma 
a  central and 
scar angiomyofibroma. 
or  calcification  as Oncocytoma  has   
a  hallmark  [21]. 
Angiomyofibroma are often found in patients with tuberous sclerosis. They are composed of fat,
a  varying  ultrasonic 
Angiomyofibroma  appearance, 
are  often  found  but 
in  may  have 
patients  a  central 
with  scar 
tuberous  or  calcification 
sclerosis.  as composed 
They  are  a  hallmark 
of [21]. 
fat, 
smooth muscle tissue and
Angiomyofibroma 
vascular elements.
are  often  found  in 
The with 
echogenicity
patients The 
is governed
tuberous  sclerosis. 
by are 
the composed 
They by 
composition of these
of  fat, 
smooth  muscle  tissue and vascular  elements.  echogenicity  is  governed  the  composition  of 
elements, but the lesion is often hyperechoic (Figures 11 and 12) [22].
smooth  muscle  tissue and vascular  elements.  The  echogenicity  is  governed  by  the  composition  of 
these elements, but the lesion is often hyperechoic (Figures 11 and 12) [22]. 
these elements, but the lesion is often hyperechoic (Figures 11 and 12) [22]. 

 
 
Figure 11. Angiomyolipoma seen as a hyperechoic mass in the upper pole of an adult kidney. 
Figure 11. Angiomyolipoma seen as a hyperechoic mass in the upper pole of an adult kidney.
Figure 11. Angiomyolipoma seen as a hyperechoic mass in the upper pole of an adult kidney. 

 
Figure  12.  Patient  with  tuberous  sclerosis  and  multiple  angiomyolipomas  in  
the  kidney. 
Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line. 
Figure  12.  Patient  with  tuberous  sclerosis  and  multiple  angiomyolipomas  in  the  kidney. 
Figure 12. Patient with tuberous sclerosis and multiple angiomyolipomas in the kidney. Measurement
Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line. 
of kidney length on the US image is illustrated by ‘+’ and a dashed line.
Benign tumors are difficult to separate from malignant tumors using US. Thus, solid renal masses 
Benign tumors are difficult to separate from malignant tumors using US. Thus, solid renal masses 
found  on  US  are  difficult  to  classify  and  should  be  further  evaluated  with  CT.  In  special  cases  of 
Benign tumors are difficult to separate from malignant tumors using US. Thus, solid renal masses
found  on  US  are  difficult  to  classify  and  should  be  further  evaluated  with  CT.  In  special  cases  of 
cystic or solid renal masses, additional US guided biopsy or drainage is performed to identify the 
foundhistologic tumor type before a decision on surgery is made [23]. 
on US are difficult to classify and should be further evaluated with CT. In special cases of cystic
cystic or solid renal masses, additional US guided biopsy or drainage is performed to identify the 
or solid renal masses, additional US guided biopsy or drainage is performed to identify the histologic
histologic tumor type before a decision on surgery is made [23]. 
6. Hydronephrosis 
tumor type before a decision on surgery is made [23].
6. Hydronephrosis 
One  of  the  primary  indications  for  referral  to  US  evaluation  of  the  kidneys  is  evaluation  of   
6. Hydronephrosis
One  of  the  primary  indications  for  referral  to  US  evaluation  of  the  kidneys  is  evaluation  of   
the urinary collecting system [4]. Enlargement of the urinary collecting system is usually related to 
the urinary collecting system [4]. Enlargement of the urinary collecting system is usually related to 
urinary obstruction and can include the pelvis, the calyces and the ureter. Hydronephrosis is seen as 
One of the primary indications for referral to US evaluation of the kidneys is evaluation of the
urinary obstruction and can include the pelvis, the calyces and the ureter. Hydronephrosis is seen as 
urinary collecting system [4]. Enlargement of the urinary collecting system is usually related to urinary
 
obstruction and can include the pelvis, the calyces   and the ureter. Hydronephrosis is seen as an
Diagnostics 2016, 6, 2 8 of 18

Diagnostics 2016, 6, 0000    2 of 18 
anechoic fluid-filled interconnected space with enhancement within the renal sinus, and normally, the
Diagnostics 2016, 6, 0000    2 of 18 
dilated
an pelvis
anechoic canfluid‐filled 
be differentiated from thespace 
interconnected  dilated calyces.
with  enhancement  within  the  renal  sinus,  and 
Several conditions can result in urinary obstruction. In both adults
normally, the dilated pelvis can be differentiated from the dilated calyces. 
an  anechoic  fluid‐filled  interconnected  space  with  enhancement  and
within  children,
the  masses,
renal  sinus,  and such
Several conditions can result in urinary obstruction. In both adults and children, masses, such 
as abscesses and tumors, can compress the ureter. In children, hydronephrosis can be caused by
normally, the dilated pelvis can be differentiated from the dilated calyces. 
as  abscesses  and  tumors,  can  compress 
ectopic the  ureter.  In  children,  hydronephrosis  can  posterior
be  caused urethral
Several conditions can result in urinary obstruction. In both adults and children, masses, such 
ureteropelvic junction obstruction, inserted ureter, primary megaureter and by 
ureteropelvic junction obstruction, ectopic inserted ureter, primary megaureter and posterior urethral 
as  abscesses  and  tumors,  can  compress  the  ureter.  In  children,  hydronephrosis  can 
valve (Figure 13). In the latter, both kidneys will be affected. In adults, hydronephrosis can be by  be  caused  caused
valve (Figure 13). In the latter, both kidneys will be affected. In adults, hydronephrosis can be caused 
ureteropelvic junction obstruction, ectopic inserted ureter, primary megaureter and posterior urethral 
by urolithiasis, obstructing the outlet of the renal pelvis or the ureter, and compression of the ureter
by urolithiasis, obstructing the outlet of the renal pelvis or the ureter, and compression of the ureter 
from,valve (Figure 13). In the latter, both kidneys will be affected. In adults, hydronephrosis can be caused 
e.g., pregnancy and retroperitoneal fibrosis [24]. Urolithiasis is the most common cause of
from,  e.g.,  pregnancy  and  retroperitoneal  fibrosis  [24].  Urolithiasis  is  the  most  common  cause  of 
by urolithiasis, obstructing the outlet of the renal pelvis or the ureter, and compression of the ureter 
hydronephrosis in the adult patient and has a prevalence of 10%–15% [25].
hydronephrosis in the adult patient and has a prevalence of 10%–15% [25]. 
from,  e.g.,  pregnancy  and  retroperitoneal  fibrosis  [24].  Urolithiasis  is  the  most  common  cause  of 
hydronephrosis in the adult patient and has a prevalence of 10%–15% [25]. 

 
 
Figure 13. Hydronephrosis due to ureteropelvic junction obstruction in a pediatric patient. 
Figure 13. Hydronephrosis due to ureteropelvic junction obstruction in a pediatric patient.
Figure 13. Hydronephrosis due to ureteropelvic junction obstruction in a pediatric patient. 
Under normal conditions, the ureter is not seen with US. However, in, e.g., urinary obstruction 
Under normal conditions, the ureter is not seen with US. However, in, e.g., urinary obstruction
and vesicoureteric reflux with dilation of the ureter, the proximal part in continuation with the renal 
Under normal conditions, the ureter is not seen with US. However, in, e.g., urinary obstruction 
and vesicoureteric reflux with dilation of the ureter, the proximal part in continuation with the renal
pelvis, as well as the distal part near the ostium can be evaluated (Figure 14). 
and vesicoureteric reflux with dilation of the ureter, the proximal part in continuation with the renal 
pelvis, as well as the distal part near the ostium can be evaluated (Figure 14).
pelvis, as well as the distal part near the ostium can be evaluated (Figure 14). 

 
 
Figure 14. Bilateral dilatation of the ureters due to vesicoureteric reflux in a pediatric patient. 
Figure 14. Bilateral dilatation of the ureters due to vesicoureteric reflux in a pediatric patient. 
Figure 14. Bilateral dilatation
The  hydronephrosis  of the
is  typically  ureters
graded  due to and 
visually  vesicoureteric refluxinto 
can  be  divided  in a five 
pediatric patient.
categories  going 
from The 
a  slight 
hydronephrosis  is  typically  graded  visually  and  can  be  divided  into  five  categories  going   
expansion  of  the  renal  pelvis  to  end‐stage  hydronephrosis  with  cortical  thinning 
The hydronephrosis is typically graded visually and can be divided into five categories going from
(Figure 15) [16]. The evaluation of hydronephrosis can also include measures of calyces at the level 
from  a  slight  expansion  of  the  renal  pelvis  to  end‐stage  hydronephrosis  with  cortical  thinning   
a slight expansion of the renal pelvis to end-stage hydronephrosis with cortical thinning (Figure 15) [16].
of the neck in the longitudinal scan plane, of the dilated renal pelvis in the transverse scan plane and 
(Figure 15) [16]. The evaluation of hydronephrosis can also include measures of calyces at the level 
The evaluation of hydronephrosis can also include measures of calyces at the level of the neck in
the cortical thickness, as explained previously (Figures 16 and 17) [4]. 
of the neck in the longitudinal scan plane, of the dilated renal pelvis in the transverse scan plane and 
the longitudinal scan plane, of the dilated renal pelvis in the transverse scan plane and the cortical
the cortical thickness, as explained previously (Figures 16 and 17) [4]. 
 
thickness, as explained previously (Figures 16 and 17) [4].
 
Diagnostics 2016, 6, 2 9 of 18
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Figure 15. End‐stage hydronephrosis with cortical thinning. Measurement of pelvic dilatation on the 
Figure 15. End-stage hydronephrosis with cortical thinning. Measurement of pelvic dilatation on the
US image is illustrated by ‘+’ and a dashed line.   
Figure 15. End‐stage hydronephrosis with cortical thinning. Measurement of pelvic dilatation on the 
US image is illustrated by ‘+’ and a dashed line.
US image is illustrated by ‘+’ and a dashed line. 
Figure 15. End‐stage hydronephrosis with cortical thinning. Measurement of pelvic dilatation on the 
US image is illustrated by ‘+’ and a dashed line. 

 
  cortical  atrophy.   
Figure  16.  Hydronephrosis  with  dilated  anechoic  pelvis  and  calyces,  along  with 
 
The width of a calyx is measured on the US image in the longitudinal scan plane, and illustrated by 
Figure  16.  Hydronephrosis  with  dilated  anechoic  pelvis  and  calyces,  along  with  cortical  atrophy.   
Figure 16. Hydronephrosis with dilated anechoic pelvis and calyces, along with cortical atrophy.
‘+’ and a dashed line. 
The width of a calyx is measured on the US image in the longitudinal scan plane, and illustrated by 
Figure  16.  Hydronephrosis  with  dilated  anechoic  pelvis  and  calyces,  along  with  cortical  atrophy.   
The width of a calyx is measured on the US image in the longitudinal scan plane, and illustrated by ‘+’
‘+’ and a dashed line. 
The width of a calyx is measured on the US image in the longitudinal scan plane, and illustrated by 
and a dashed line.
‘+’ and a dashed line. 

 
  in  the  transverse   
Figure  17.  Same  patient  as  in  Figure  16  with  measurement  of  the  pelvis  dilation 
scan plane illustrated on the US image with ‘+’ and a dashed line.    in  the  transverse   
Figure  17.  Same  patient  as  in  Figure  16  with  measurement  of  the  pelvis  dilation 
scan plane illustrated on the US image with ‘+’ and a dashed line. 
Figure  17.  Same  patient  as  in  Figure  16  with  measurement  of  the  pelvis  dilation  in  the  transverse   
Figure
If  the Same
17. fluid patient as in Figure
in  the  dilated  16 with
collecting  measurement
system  of the
has  echoes, 
scan plane illustrated on the US image with ‘+’ and a dashed line. 
pelvis dilation
pyonephrosis  in thebe 
should  transverse scan
excluded  by 
plane If illustrated
the  fluid on the US
in  the  image
dilated  with ‘+’ and
collecting  a dashed
system  line. pyonephrosis  should  be  excluded  by 
has  echoes, 
clinical exam, blood analysis and, in special cases, puncture or drainage. Hydronephrosis can also be 
clinical exam, blood analysis and, in special cases, puncture or drainage. Hydronephrosis can also be 
If  the  fluid  in  the  dilated  collecting  system  has  echoes,  pyonephrosis  should  be  excluded  by 
If the fluid in the dilated collecting system has   echoes, pyonephrosis should be excluded by
clinical exam, blood analysis and, in special cases, puncture or drainage. Hydronephrosis can also be 
clinical exam, blood analysis and, in special cases,  puncture or drainage. Hydronephrosis can also
 
Diagnostics 2016, 6, 2 10 of 18

be caused by non-obstructive
Diagnostics 2016, 6, 0000   
conditions, such as brisk diuresis in patients treated with diuretics,
2 of 18 
in
pregnant women and in
Diagnostics 2016, 6, 0000  children
  with vesicoureteral reflux [24]. 2 of 18 
caused  by  non‐obstructive  conditions,  such  as  brisk  diuresis  in  patients  treated  with  diuretics,  in 
7. Renal Calculi
caused  by  non‐obstructive  conditions,  such  as  brisk  diuresis  in  patients  treated  with  diuretics,  in 
pregnant women and in children with vesicoureteral reflux [24]. 
pregnant women and in children with vesicoureteral reflux [24]. 
Even though US has a lower sensitivity and specificity than CT for the detection of urolithiasis, US,
7. Renal Calculi 
if available, is recommended as the initial imaging modality in patients with renal colic and suspected
7. Renal Calculi 
urolithiasis [26,27]. US has no risk of radiation, is reproducible and inexpensive, and the outcome is  not
Even though US has a lower sensitivity and specificity than CT for the detection of urolithiasis, 
Even though US has a lower sensitivity and specificity than CT for the detection of urolithiasis, 
US,  if  available,  is  recommended  as  the  initial  imaging  modality  in  patients  with  renal  colic  and   
significantly different for patients with suspected urolithiasis undergoing initial US exam compared to
US,  if  available,  is  recommended  as  the  initial  imaging  modality  in  patients  with  renal  colic  and 
suspected urolithiasis [26,27]. US has no risk of radiation, is reproducible and inexpensive, and the 
patients undergoing initial CT exam [26,28].
suspected urolithiasis [26,27]. US has no risk of radiation, is reproducible and inexpensive, and the 
outcome is not significantly different for patients with suspected urolithiasis undergoing initial US 
With US, larger stones (>5–7 mm) within the kidney, i.e., in the calyces, the pelvis and the
outcome is not significantly different for patients with suspected urolithiasis undergoing initial US 
exam compared to patients undergoing initial CT exam [26,28]. 
pyelouretericWith junction, canstones 
be differentiated, especially
exam compared to patients undergoing initial CT exam [26,28]. 
US,  larger  (>5–7  mm)  within  in the cases
the  kidney,  with
i.e.,  in  the accompanying hydronephrosis
calyces,  the  pelvis  and  the 
(Figures 18 andUS, 
With 
pyeloureteric  19)junction, 
[26,29].
larger  Hyperechoic
stones 
can (>5–7  mm)  stones areespecially 
within  the 
be  differentiated,  seen with
kidney,  in accompanying
i.e.,  in the 
the cases 
calyces,  posterior
the 
with  pelvis  shadowing.
and 
accompanying the 
Additional twinkling
pyeloureteric 
hydronephrosis  artifacts
junction, 
(Figures  below
can 
18  the stone
be  19) 
and  can
differentiated, 
[26,29].  often be seen
especially 
Hyperechoic  in  using
stones  Doppler
the are 
cases  USaccompanying 
seen  with 
with  [30]. Large stones
fillinghydronephrosis  (Figures  18  and 
are19)  [26,29]. 
coralHyperechoic  stones  are  seen and
with 
posterior shadowing. Additional twinkling artifacts below the stone can often be seen using Doppler 
the entire collecting system called stones or staghorn calculi areaccompanying 
easily visualized
posterior shadowing. Additional twinkling artifacts below the stone can often be seen using Doppler 
US [30]. Large stones filling the entire collecting system are called coral stones or staghorn calculi 
with US (Figure 20). Stones in the ureters are usually not visualized with US due to the air-filled
US [30]. Large stones filling the entire collecting system are called coral stones or staghorn calculi 
and are easily visualized with US (Figure 20). Stones in the ureters are usually not visualized with 
intestines obscuring the insonation window. However, ureteral stones near the ostium can be visualized
and are easily visualized with US (Figure 20). Stones in the ureters are usually not visualized with 
US due to the air‐filled intestines obscuring the insonation window. However, ureteral stones near the 
with a scan position over the bladder. An exam of the ureteric orifices and the excretion of urine to
US due to the air‐filled intestines obscuring the insonation window. However, ureteral stones near the 
ostium can be visualized with a scan position over the bladder. An exam of the ureteric orifices and 
the bladder can be performed by inspecting the ureteric jets in the bladder with color Doppler US
ostium can be visualized with a scan position over the bladder. An exam of the ureteric orifices and 
the excretion of urine to the bladder can be performed by inspecting the ureteric jets in the bladder 
(Figure 21) [4,24].
the excretion of urine to the bladder can be performed by inspecting the ureteric jets in the bladder 
with color Doppler US (Figure 21) [4,24]. 
with color Doppler US (Figure 21) [4,24]. 

 
 
Figure 18. Renal stone located at the pyeloureteric junction with accompanying hydronephrosis. 
Figure 18. Renal stone located at the pyeloureteric junction with accompanying hydronephrosis.
Figure 18. Renal stone located at the pyeloureteric junction with accompanying hydronephrosis. 

 
 
Figure  19.  Centrally‐located  stone  with  posterior  shadowing.  No  hydronephrosis  is  present. 
Figure  19.  Centrally‐located  stone  with  posterior  shadowing.  No  hydronephrosis  is  present. 
Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line. 
Figure 19. Centrally-located stone with posterior shadowing. No hydronephrosis is present.
Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line. 
Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line.
 
 
Diagnostics 2016, 6, 2 11 of 18
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Figure 20. Staghorn calculi filling the entire collecting system and creating pronounced shadowing. 
Figure 20. Staghorn calculi filling the entire collecting system and creating pronounced shadowing.
Figure 20. Staghorn calculi filling the entire collecting system and creating pronounced shadowing. 
 
Figure 20. Staghorn calculi filling the entire collecting system and creating pronounced shadowing. 

 
 
Figure  21.  Left  hydroureter  with  ureteric  jet.  No  stone  is  visible.  The  red  color  in  the  color  box 
Figure  21.  Left  hydroureter  with  ureteric  jet.  No  stone  is  visible.  The  red  color  in  the  color  box 
represents motion towards the transducer as defined by the color bar. 
Figure 21. Left hydroureter with ureteric jet. No stone is visible. The red color in the color box
represents motion towards the transducer as defined by the color bar.   
represents motion towards the transducer as defined by the color bar.
8. Chronic Kidney Disease 
Figure  21.  Left  hydroureter  with  ureteric  jet.  No  stone  is  visible.  The  red  color  in  the  color  box 
8. Chronic Kidney Disease 
represents motion towards the transducer as defined by the color bar. 
8. Chronic US Kidney
is  useful  for  diagnostic  and  prognostic  purposes  in  chronic  kidney  disease.  Whether  the 
Disease
US  is  useful 
underlying  for  diagnostic 
pathologic  and 
change  is  prognostic sclerosis, 
glomerular  purposes tubular 
in  chronic  kidney interstitial 
atrophy,  disease.  Whether 
fibrosis the 
or 
8. Chronic Kidney Disease 
underlying  pathologic  change  is  glomerular  sclerosis,  tubular  atrophy, kidney
interstitial  fibrosis  or 
US is useful for diagnostic and prognostic purposes in chronic
inflammation, the result is often increased echogenicity of the cortex. The echogenicity of the kidney  disease. Whether
inflammation, the result is often increased echogenicity of the cortex. The echogenicity of the kidney 
US  is 
be  useful 
related for 
to  diagnostic 
the  and  prognostic 
echogenicity  of  either  purposes 
the  liver  in 
or chronic 
the  kidney 
the underlying pathologic change is glomerular sclerosis, tubular atrophy, interstitial fibrosis or
should  spleen  disease. 
(Figures  22  Whether 
and  23)  the 
[2]. 
should  be the
underlying 
inflammation, related 
result to isthe 
pathologic  echogenicity 
change 
often of  either 
is  glomerular 
increased the  liver 
sclerosis, 
echogenicity or  cortex.
the  spleen 
of tubular 
the The(Figures 
atrophy,  22  and 
interstitial 
Moreover, decreased renal size and cortical thinning are also often seen and especially when disease 
echogenicity of23) 
the[2]. 
fibrosis  or 
kidney
Moreover, decreased renal size and cortical thinning are also often seen and especially when disease 
inflammation, the result is often increased echogenicity of the cortex. The echogenicity of the kidney 
progresses (Figures 24 and 25). However, kidney size correlates to height, and short persons tend to 
should be related to the echogenicity of either the liver or the spleen (Figures 22 and 23) [2]. Moreover,
progresses (Figures 24 and 25). However, kidney size correlates to height, and short persons tend to 
should  be  related  to  the  echogenicity  of  either  the  liver  or  the  spleen  (Figures  22  and  23)  [2]. 
have small kidneys; thus, kidney size as the only parameter is not reliable [2]. 
decreased renal size and cortical thinning are also often seen and especially when disease progresses
have small kidneys; thus, kidney size as the only parameter is not reliable [2]. 
Moreover, decreased renal size and cortical thinning are also often seen and especially when disease 
(Figures 24 and 25). However, kidney size correlates to height, and short persons tend to have small
progresses (Figures 24 and 25). However, kidney size correlates to height, and short persons tend to 
kidneys; thus, kidney size as the only parameter is not reliable [2].
have small kidneys; thus, kidney size as the only parameter is not reliable [2]. 

 
 
Figure 22. Chronic renal disease caused by glomerulonephritis with increased echogenicity and reduced 
Figure 22. Chronic renal disease caused by glomerulonephritis with increased echogenicity and reduced 
cortical thickness. Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line. 
 
cortical thickness. Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line. 
Figure 22. Chronic renal disease caused by glomerulonephritis with increased echogenicity and reduced 
 
Figure 22. Chronic renal disease caused by glomerulonephritis with increased echogenicity and
cortical thickness. Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line. 
 
reduced cortical thickness. Measurement of kidney length on the US image is illustrated by ‘+’ and a
dashed line.
 
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Figure 23. Nephrotic syndrome. Hyperechoic kidney without demarcation of cortex and medulla. 
Figure 23. Nephrotic syndrome. Hyperechoic kidney without demarcation   of cortex and medulla.
Figure 23. Nephrotic syndrome. Hyperechoic kidney without demarcation of cortex and medulla. 
Figure 23. Nephrotic syndrome. Hyperechoic kidney without demarcation of cortex and medulla. 

 
 
Figure  24.  Chronic  pyelonephritis  with  reduced  kidney  size  and  focal  cortical  thinning. 
Figure   
24.  Chronic  pyelonephritis  with  reduced  kidney  size  and  focal  cortical 
Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line.  thinning. 
Figure 24. Chronic pyelonephritis with reduced kidney size and focal cortical thinning. Measurement
Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line. 
Figure  24.  Chronic  pyelonephritis  with  reduced  kidney  size  and  focal  cortical  thinning. 
of kidney length on the US image is illustrated by ‘+’ and a dashed line.
Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line. 

 
 
Figure 25. End‐stage chronic kidney disease with increased echogenicity, homogenous architecture 
 
Figure 25. End‐stage chronic kidney disease with increased echogenicity, homogenous architecture 
without  visible  differentiation  between  parenchyma  and  renal  sinus  and  reduced  kidney  size. 
without  visible  differentiation  between  parenchyma  and  renal  sinus  and  reduced  kidney  size. 
Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line. 
Figure 25. End‐stage chronic kidney disease with increased echogenicity, homogenous architecture 
Figure 25. End-stage chronic kidney disease with increased echogenicity, homogenous architecture
Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line. 
without  visible  differentiation  between  parenchyma  and  renal  sinus  and  reduced  kidney  size. 
without visible differentiation between parenchyma and renal sinus and reduced kidney size.
Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line. 
Measurement of kidney length on the US image is illustrated by ‘+’ and a dashed line.
 
 
 
Diagnostics 2016, 6, 2 13 of 18
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9. Acute Renal Injury
9. Acute Renal Injury 
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9. Acute Renal Injury 
The acute changes in the kidney are often examined with US as the first‐line modality, where 
The acute changes in the kidney are often examined with US as the first-line modality, where CT
9. Acute Renal Injury 
CT and magnetic resonance imaging (MRI) are used for the follow‐up examinations and when US 
and magneticThe acute changes in the kidney are often examined with US as the first‐line modality, where 
resonance imaging (MRI) are used for the follow-up examinations and when US fails
fails  The acute changes in the kidney are often examined with US as the first‐line modality, where 
to  demonstrate  abnormalities  [31].  In  evaluation  of  the  acute  changes  in  the  kidney,  the 
CT and magnetic resonance imaging (MRI) are used for the follow‐up examinations and when US 
to demonstrate abnormalities [31]. In evaluation of the acute changes in the kidney, the echogenicity
echogenicity of the renal structures, the delineation of the kidney, the renal vascularity, kidney size 
fails  to  demonstrate  abnormalities  [31].  In  evaluation  of  the  acute  changes  in  the  kidney,  the 
of theCT and magnetic resonance imaging (MRI) are used for the follow‐up examinations and when US 
renal structures, the delineation of the kidney, the renal vascularity, kidney size and focal
and focal abnormalities are observed (Figures 26 and 27). CT is preferred in renal traumas, but US is 
echogenicity of the renal structures, the delineation of the kidney, the renal vascularity, kidney size 
fails  to  demonstrate  abnormalities  [31].  In  evaluation  of  the  acute  changes  in  the  kidney,  the 
abnormalities
used 
are observed (Figures 26 and 27). CT is preferred in renal traumas, but US is used for
for  follow‐up,  especially  in  the  patients  suspected  for  the  formation  of  urinomas  [32]   
and focal abnormalities are observed (Figures 26 and 27). CT is preferred in renal traumas, but US is 
echogenicity of the renal structures, the delineation of the kidney, the renal vascularity, kidney size 
follow-up, especially
(Figure 28). 
used  for  in the
follow‐up,  patientsin 
especially  suspected for the
the  patients  formation
suspected  for  of urinomas
the  [32]
formation  of  (Figure 28).[32]   
urinomas 
and focal abnormalities are observed (Figures 26 and 27). CT is preferred in renal traumas, but US is 
(Figure 28). 
used  for  follow‐up,  especially  in  the  patients  suspected  for  the  formation  of  urinomas  [32]   
(Figure 28). 

 
  delineation  of   
Figure  26.  Acute  pyelonephritis  with  increased  cortical  echogenicity  and  blurred 
Figure 26. Acute pyelonephritis with increased cortical echogenicity and blurred delineation of the
  delineation 
the upper pole. 
Figure  26.  Acute  pyelonephritis  with  increased  cortical  echogenicity  and  blurred  of   
upper pole.
the upper pole. 
Figure  26.  Acute  pyelonephritis  with  increased  cortical  echogenicity  and  blurred  delineation  of   
the upper pole. 

 
Figure  27.  Postoperative  renal  failure  with increased  cortical  echogenicity  and  kidney  size. Biopsy 
27.  Postoperative  renal  failure  with increased  cortical  echogenicity  and  kidney  size. Biopsy 
showed acute tubular necrosis. 
Figure 
Figure 27. Postoperative renal failure with increased cortical echogenicity and kidney size. Biopsy
showed acute tubular necrosis. 
Figure  27.  Postoperative  renal  failure  with increased  cortical  echogenicity  and  kidney  size. Biopsy 
showed acute tubular necrosis.
showed acute tubular necrosis. 

 
  collection  below   
Figure  28.  Renal  trauma  with  laceration  of  the  lower  pole  and  subcapsular  fluid 
the kidney.    collection  below   
Figure  28.  Renal  trauma  with  laceration  of  the  lower  pole  and  subcapsular  fluid 
the kidney. 
Figure  28.  Renal  trauma  with  laceration  of  the  lower  pole  and  subcapsular  fluid  collection  below   
 
Figure 28. Renal trauma with laceration of the lower pole and subcapsular fluid collection below
the kidney. 
the kidney.  
 
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10. US-Guided Intervention

10. US‐Guided Intervention 
Sonography is the modality of choice for guidance when performing intervention in the kidney,
Sonography is the modality of choice for guidance when performing intervention in the kidney, 
whether it is kidney biopsy, percutaneous nephrostomy or abscess drainage. Historically, thermal
whether it is kidney biopsy, percutaneous nephrostomy or abscess drainage. Historically, thermal 
ablation of renal tumors is performed under CT guidance, as the risk of injuring neighboring
ablation of renal tumors is performed under CT guidance, as the risk of injuring neighboring intestines 
intestines during the US-guided procedure was considered too high due to poor identification of the
during the US‐guided procedure was considered too high due to poor identification of the moving 
moving bowels
bowels  [4,23]. However,
[4,23].  However,  recent recent guidelines
guidelines  for  for renal
renal  interventional
interventional  USinclude 
US  include radiofrequency, 
radiofrequency,
microwave and cryoablation with US as the ideal imaging guide [33,34].
microwave and cryoablation with US as the ideal imaging guide [33,34]. 
For percutaneous
For  nephrostomy and 
percutaneous  nephrostomy  and abscess 
abscess drainage, 
drainage, either 
either the 
the one‐step 
one-step or 
or the
the  Seldinger
Seldinger 
technique is used. Using the Seldinger technique, the cavity is punctured with a sharp hollow
technique  is  used.  Using  the  Seldinger  technique,  the  cavity  is  punctured  with  a  sharp  hollow 
needle, called a trocar. A round-tipped guidewire is then advanced through the lumen of the trocar,
needle, called a trocar. A round‐tipped guidewire is then advanced through the lumen of the trocar, 
and after withdrawal of the trocar, a catheter or nephrostomy can be inserted over the guidewire to
and after withdrawal of the trocar, a catheter or nephrostomy can be inserted over the guidewire to 
ensure correct placement. The one-step technique is when insertion of the drain or nephrostomy is
ensure correct placement. The one‐step technique is when insertion of the drain or nephrostomy is 
done without the aid of a guidewire [4]. The interventions are performed under local anesthesia and
done without the aid of a guidewire [4]. The interventions are performed under local anesthesia and 
in a sterile setup. The procedures can be carried out with or without needle guidance according to
in a sterile setup. The procedures can be carried out with or without needle guidance according to 
preference, experience and setup (Figure 29) [33,34].
preference, experience and setup (Figure 29) [33,34]. 

 
Figure 29. (A) Percutaneous nephrostomy tube placed through a calyx in the lower pole of a kidney 
Figure 29. (A) Percutaneous nephrostomy tube placed through a calyx in the lower pole of a kidney
with hydronephrosis. (B) The pigtail catheter is placed in the dilated calyx. The tube in (A) and the 
with hydronephrosis. (B) The pigtail catheter is placed in the dilated calyx. The tube in (A) and the
pigtail in (B) are marked with white arrows. 
pigtail in (B) are marked with white arrows.

11. CEUS, Image Fusion and Elastography 
11. CEUS, Image Fusion and Elastography
CEUS can evaluate microvasculature, which color Doppler US is unable to detect. In renal US 
CEUS can evaluate microvasculature, which color Doppler US is unable to detect. In renal US
examination,  CEUS  can  be  used  to  differentiate  tumor  and  pseudotumor,  such  as  prominent 
examination, CEUS can be used to differentiate tumor and pseudotumor, such as prominent columns
columns  of  Bertin.  Pseudotumors  enhance  as  adjacent  renal  tissue.  The  use  of  CEUS  is 
of Bertin. Pseudotumors enhance as adjacent renal tissue. The use of CEUS is recommended in special
recommended in special cases to distinguish between cystic and hypovascularized solid lesions, to 
cases to distinguish between cystic and hypovascularized solid lesions, to characterize complex cysts,
characterize complex cysts, abscesses, traumatic lesions and ischemic lesions [35,36]. Solid malignant 
abscesses, traumatic lesions and ischemic lesions [35,36]. Solid malignant tumors in the kidney do
tumors in the kidney do not exhibit specific enhancement patterns like some liver lesions, and no 
not exhibit specific enhancement patterns like some liver lesions, and no valid enhancement criteria
valid enhancement criteria between benign and malignant renal lesions have been proposed [37,38]. 
between benign and malignant renal lesions have been proposed [37,38]. However, CEUS is used
However, CEUS is used in some patients after ablation of renal cell carcinoma to evaluate contrast 
in some patients after ablation of renal cell carcinoma to evaluate contrast uptake in the treated area
uptake in the treated area (Figure 30). 
(Figure 30).

 
Diagnostics 2016, 6, 2 15 of 18
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Figure  30. Renal
Renal  cell 
cellcell  carcinoma 
carcinoma successfully 
successfully treated 
treatedtreated  with  thermal asablation, 
with thermal as  no  contrast 
Figure
Figure 30.
30.  Renal  carcinoma  successfully  with  ablation, no contrast
thermal  ablation,  as enhancement
no  contrast 
enhancement is seen. 
is seen.
enhancement is seen. 

Image  fusion
Image
Image  fusion  of 
fusion  of  ultrasound
of ultrasound  with 
ultrasound  with  a 
with a  previously
a previously  recorded 
previously  recorded  dataset
recorded dataset  of 
dataset  of  CT
of CT  or
CT  or  other
or  other  modalities
other  modalities  is
modalities  is 
is 
rarely used in renal US. Reports on image fusion using CEUS or US combined with CT or MRI in the 
rarely used in renal US. Reports on image fusion using CEUS or US combined with CT or MRI in
rarely used in renal US. Reports on image fusion using CEUS or US combined with CT or MRI in the 
examination 
the examinationof  renal 
examination  of  renal  lesions 
of renal and 
lesions
lesions  and
and  in in
in  difficult  US‐guided 
difficultUS‐guided 
difficult  renal 
US-guidedrenal  interventions 
renalinterventions  have 
interventionshave  been 
have been  published 
been published
published 
(Figure 31) [39]. However, no recommendations have been published so far. 
(Figure 31) [39]. However, no recommendations have been published so far.
(Figure 31) [39]. However, no recommendations have been published so far. 

  
Figure  31.  Unspecific  cortical lesion on  CT  is  confirmed  cystic  and  benign  with  contrast‐enhanced 
Figure  31.  Unspecific  cortical lesion on  CT  is  confirmed  cystic  and  benign  with  contrast‐enhanced 
Figure 31. Unspecific cortical lesion on CT is confirmed cystic and benign with contrast-enhanced
ultrasound (CEUS) using image fusion. 
ultrasound (CEUS) using image fusion. 
ultrasound (CEUS) using image fusion.
Elastography  is 
Elastography  is  a 
a  US 
US  method 
method  to 
to  visualize 
visualize  the 
the  elasticity 
elasticity  of 
of  tissue. 
tissue.  Preliminary  reports 
reports  on  US 
US 
Elastography is a US method to visualize the elasticity of tissue. Preliminary 
Preliminary reports on 
on US
elastography  used 
elastography used on 
used onon  transplanted 
transplanted  kidneys 
kidneys  to  evaluate 
to  evaluate  cortical 
cortical  fibrosis  have  been  published 
elastography transplanted kidneys to evaluate cortical fibrosisfibrosis  have 
have been been  published 
published showing
showing promising results (Figure 32) [40]. 
showing promising results (Figure 32) [40]. 
promising results (Figure 32) [40].

  
Diagnostics 2016, 6, 2 16 of 18
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Figure 32. Strain elastography of a normal kidney. Red depicts soft areas, and blue depicts hard areas 
Figure 32. Strain elastography of a normal kidney. Red depicts soft areas, and blue depicts hard areas
relative to the entire elastography image. Note that the medulla is softer than the cortex. A color bar 
relative to the entire elastography image. Note that the medulla is softer than the cortex. A color bar is
is shown to the left of the image, where ‘S’ and ‘H’ denote soft and hard tissue, respectively. 
shown to the left of the image, where ‘S’ and ‘H’ denote soft and hard tissue, respectively.
12. Conclusions 
12. Conclusions
Renal US is a versatile and useful examination. US is an accessible, inexpensive and fast aid for 
Renal US is a versatile and useful examination. US is an accessible, inexpensive and fast aid for
decision‐making in patients with renal symptoms and for guidance in renal intervention. However, 
decision-making in patients
renal  US  has  certain  with renal
limitations,  and  symptoms and forsuch 
other  modalities,  guidance
as  CT inand 
renal intervention.
MRI,  However,
should  always  be 
renal US has certain limitations, and other modalities, such as CT and MRI, should always be
considered as supplementary imaging modalities in the assessment of renal disease. 
considered as supplementary imaging modalities in the assessment of renal disease.
Acknowledgments: We thank Kim Krarup for providing images of a nephrostomy. 

We thank Kim Krarup for providing images of a nephrostomy.

Author Contributions: Kristoffer Lindskov Hansen and Caroline Ewertsen conducted the data collection and 
Acknowledgments:
Kristoffer Lindskov Hansen wrote the manuscript. Michael Bachmann Nielsen and Caroline Ewertsen edited 
Author Contributions: Kristoffer Lindskov Hansen and Caroline Ewertsen conducted the data collection and
and proofread the manuscript. 
Kristoffer Lindskov Hansen wrote the manuscript. Michael Bachmann Nielsen and Caroline Ewertsen edited and
proofread the manuscript.
Conflicts of Interest: The authors declare no conflict of interest. 
Conflicts of Interest: The authors declare no conflict of interest.
References 
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