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      Renal Doppler Sonography – Update in Clinical Nephrology

      Nephron Clinical Practice

      S. Karger AG

      Kidney transplantation, Doppler sonography, Ultrasound, Renovascular disease

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          These days renal Doppler sonography has been established as a diagnostic tool of the daily nephrological work-up. Extra- and intrarenal flow signals are obtained for different indications. The intrarenal resistive index is the best examined parameter in the literature. However, the results have to be carefully interpreted, because different hemodynamic factors, such as heart rate, stiffness of the aorta as well as observer-dependent factors may have an impact on the level of the resistive index. The value of this non-invasive technique is discussed in detail for different renal diseases, such as acute and chronic renal failure, renal artery stenosis and for patients after renal transplantation. Being aware of several pitfalls which may lead to false results, nephrologists may use renal Doppler sonography as the first screening method of choice in the diagnostic algorithm.

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          Most cited references 15

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          Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis.

          Prospectively identifying patients whose renal function or blood pressure will improve after the correction of renal-artery stenosis has not been possible. We evaluated whether a high level of resistance to flow in the segmental arteries of both kidneys (indicated by resistance-index values of at least 80) can be used prospectively to select appropriate patients for treatment. We evaluated 5950 patients with hypertension for renal-artery stenosis using color Doppler ultrasonography, and we measured the resistance index ([1 - end-diastolic velocity divided by maximal systolic velocity] x 100). Among 138 patients who had unilateral or bilateral renal-artery stenosis of more than 50 percent of the luminal diameter and who underwent renal angioplasty or surgery, the procedure was technically successful in 131 (95 percent). Creatinine clearance and 24-hour ambulatory blood pressure were measured before renal-artery stenosis was corrected; 3, 6, and 12 months after the procedure; and yearly thereafter. The mean (+/-SD) duration of follow-up was 32+/-21 months. Among the 35 patients (27 percent) who had resistance-index values of at least 80 before revascularization, the mean arterial pressure did not decrease by 10 mm Hg or more after revascularization in 34 (97 percent). Renal function declined (defined by a decrease in the creatinine clearance; of at least 10 percent) in 28 (80 percent); 16 (46 percent) became dependent on dialysis and 10 (29 percent) died during follow-up. Among the 96 patients (73 percent) with a resistance-index value of less than 80, the mean arterial pressure decreased by at least 10 percent in all but 6 patients (6 percent) after revascularization; renal function worsened in only 3 (3 percent), all of whom became dependent on dialysis; and 3 (3 percent) died (P<0.001 for the comparison with patients with a resistance-index value of at least 80). A renal resistance-index value of at least 80 reliably identifies patients with renal-artery stenosis in whom angioplasty or surgery will not improve renal function, blood pressure, or kidney survival.
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            The renal arterial resistance index and renal allograft survival.

            Most renal transplants fail because of chronic allograft nephropathy or because the recipient dies, but no reliable factor predicting long-term outcome has been identified. We tested whether a renal arterial resistance index of less than 80 was predictive of long-term allograft survival. The renal segmental arterial resistance index (the percentage reduction of the end-diastolic flow as compared with the systolic flow) was measured by Doppler ultrasonography in 601 patients at least three months after transplantation between August 1997 and November 1998. All patients were followed for three or more years. The combined end point was a decrease of 50 percent or more in the creatinine clearance rate, allograft failure (indicated by the need for dialysis), or death. A total of 122 patients (20 percent) had a resistance index of 80 or higher. Eighty-four of these patients (69 percent) had a decrease of 50 percent or more in creatinine clearance, as compared with 56 of the 479 patients with a resistance index of less than 80 (12 percent); 57 patients with a higher resistance index (47 percent) required dialysis, as compared with 43 patients with a lower resistance index (9 percent); and 36 patients with a higher resistance index (30 percent) died, as compared with 33 patients with a lower resistance index (7 percent) (P<0.001 for all comparisons). A total of 107 patients with a higher resistance index (88 percent) reached the combined end point, as compared with 83 of those with a lower resistance index (17 percent, P<0.001). The multivariate relative risk of graft loss among patients with a higher resistance index was 9.1 (95 percent confidence interval, 6.6 to 12.7). Proteinuria (protein excretion, 1 g per day or more), symptomatic cytomegalovirus infection, and a creatinine clearance rate of less than 30 ml per minute per 1.73 m2 of body-surface area after transplantation also increased the risk. A renal arterial resistance index of 80 or higher measured at least three months after transplantation is associated with poor subsequent allograft performance and death. Copyright 2003 Massachusetts Medical Society
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              Renal resistance index and progression of renal disease.

              The progression of renal disease depends on various clinical parameters such as hypertension and proteinuria. We recently showed that an increased renal resistance index measured by duplex ultrasound is associated with a poor prognosis in patients with renal artery stenosis. We now prospectively tested the hypothesis that a high renal resistance index (greater-than-or-equal 80) predicts progression of renal disease in patients without renal artery stenosis. In 162 patients newly diagnosed with renal disease, the resistance index (1-[end diastolic velocity/maximum systolic velocity]*100) was measured in segmental arteries of both kidneys. Creatinine clearance was measured at baseline, at 3, 6, and 12 months, and then at yearly intervals thereafter (mean follow-up 3 +/- 1.4 years). The combined endpoint was a decrease of creatinine clearance by greater-than-or-equal 50%, end-stage renal disease with replacement therapy, or death. Twenty-five patients (15%) had a renal resistance index value greater-than-or-equal 80 at baseline. Nineteen (76%) had a decline in renal function; 16 (64%) progressed to dialysis, and 6 (24%) died. In comparison, in patients with renal resistance index values <80, 13 (9%) had a decline in renal function, only 7 (5%) became dialysis-dependent, and 2 (1%) died (P<0.001). In a multivariate regression analysis, only proteinuria and resistance index were independent predictors of declining renal function. A renal resistance index value of greater-than-or-equal to 80 reliably identifies patients at risk for progressive renal disease.

                Author and article information

                Nephron Clin Pract
                Nephron Clinical Practice
                S. Karger AG
                March 2006
                10 March 2006
                : 103
                : 2
                : c24-c28
                Deutsche Klinik für Diagnostik, Fachbereich Nephrologie und Hypertensiologie, Wiesbaden, Germany
                90605 Nephron Clin Pract 2006;103:c24–c28
                © 2006 S. Karger AG, Basel

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                References: 30, Pages: 1
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