Renal Disease: Transplantation - HD

Introduction to Ultrasound of the Transplant Kidney

Welcome to the double feature renal disease transplantation.

What I will talk about is ultrasound of the transplant kidney, some basics.

I want to comment a little bit on the FSO guidelines, as well.

We've heard a lot about that this morning.

She'll show you some case reports and wrap it up.

For your experience at home, who of you does transplant kidney ultrasound?

I have to look.

Okay, who doesn't do it? Okay, the ones who don't do it.

Don't be afraid. Patients with transplants go everywhere, so you will see some, even if you're not a transplant unit, they're very mobile.

Some of these people tell me they go all over the world, they go on ships.

So the chance is very high that you will meet one sooner or later.

So once again, you only see what you know.

And I want to show you some things, give you an idea of renal transplant problems that are very common.

Clinical Context and Ultrasound Techniques

But again, clinical ultrasound of the transplant kidney is, again, first of all the medical history, the physical examination, the medication, the lab findings.

This is the main thing before you think about imaging, right after that, we go on with the mode ultrasound, and I was amazed how the ultrasound picture got better and better the last 10 years, right?

We always start with a probe, 1, 2, 4 megahertz.

But if we after that switch to the linear transducer and have a look with 7, 8, 9 megahertz, we can see a lot more things and sometimes can be sure of a diagnosis and don't need to proceed.

So after that, we turn on the doppler, we do the color doppler.

We do the pulse wave Doppler, have a look at the RI values of the kidney, can see how is the resistance in the vessels, and we have a protocol, and I also recommend these protocols.

We developed it with Christoph Tama from Zurich in Switzerland, and every patient gets that as a setup.

And if we're in trouble, then to see the crown, then we go onto contrast enhanced ultrasound to make sure and to find out what's really going on.

Native Kidneys in Transplant Patients

It's a very good picture from America, which I like very much, is that these two kidneys are still in there.

And these two kidneys, which are normally inside the body of a transplant kidney, are time bombs.

Be aware of that. These people have to have an ultrasound to find out whether they've got a tumor, a new tumor inside these deceased kidneys.

Last year we had about six people with all of them interestingly papillary carcinomas of their own deceased kidneys.

And one was removed.

So as soon as there's a tumor there, kidneys then removed, and it's important to find out and not to forget about these two kidneys while you're only concentrated on the transplant kidney.

Normal Ultrasound Appearance of the Transplant Kidney

The transplant kidney, this is from our painting surgeon, Ian.

He does the transplantation and the paintings, and he can see he's a real artist, and he can see how the renal the trans renal transplant is inserted into the renal pelvis.

And how it is to say an asto most on the Wests B-mode ultrasound of the renal transplant.

This is what you see.

You can see the renal cortex, you can see the renal medulla and the pyramids, and you can see the pelvis renalis quite easily.

So let's have a look what's up here. Pause.

We can see a little catheter here, some reflex, right?

Post-Transplantation Catheter

We in our center insert this catheter right after transplantation.

Some people from Netherlands don't do it.

So it always depends which center you're transplanted.

This catheter has to be removed three months after transplantation.

Sometimes it's forgotten.

And then patient gets in trouble.

And always be aware if you see a catheter, ask where this is coming from, right.

Best answer is he's been to the urologist last week, but always be aware of that.

Measurement Techniques: Panorama Mode

So sometimes transplant kidneys get quite huge and we are in trouble with the measurements.

What is very helpful in my opinion is this panorama mode, which has got freaky names by every firm who produces this.

You can see the whole kidney and can measure the whole extent of the kidney.

But what you want to have is more detailed information.

Detailed Imaging with Linear Probes

And now I was personally amazed very much, and this was my decision to leave gastroenterology and go to nephrology.

When I was seeing that I can really see here, this is a four centimeter, be aware of how tiny lesions can be depicted by using these linear probes.

And this is a transplant kidney.

And you can see this tiny calcifications of a patient with nephrocalcinosis.

And you can see they're rising in the periphery of the medullary area.

And you can really understand the disease of a patient who's suffering from that and can work at the nephrologist and can change medication and things.

So it's really amazing.

Examples of Pathological Findings

This is a patient, yes, young people on transplantation.

He got this kidney from his mother.

She was a donor. And this young guy, he was 16 years old, got in his rebellion phase, left Germany, and when he came back, he took no medication.

His kid, the kidney of his mother looked like that, that was a transplant kidney.

This is a really deceased transplant kidney.

And this was a young guy who did stop his immunosuppressive therapy and then a renal transplant looks like that. Rare cases, yeah.

Thanks God, right.

Biopsy in Transplant Kidneys

Then in nephrology, if you don't know what to do, you always perform a biopsy.

Yeah. And this is a biopsy of the transplant kidney, of course.

You can visualize, we only do one biopsy, and then you visualize and take some specimen and get it to the nephropathologist, and he tells you what's wrong with the transplant kidney.

Some people do this specimen also after protocol, not to miss a rejection, for example.

Doppler Ultrasound

Color doppler is important for the renal transplant.

You can see tiny vessels and can really get an idea of what is going on here.

Spectral Doppler gives you an idea about the RI values, and some people say, oh, what are you doing?

You're measuring.

But it's important to get an idea of the RI values.

There were some very good papers showing that the course of these RI values of the transplant kidney over the time is quite helpful and also helps you if you're completely short of sleep and you get a patient nighttime to make sure that there's nothing going wrong.

If you have your protocol and always stand with the protocol, if you've got this patient, for example, you say, okay, spot on.

I can go to bed.

And if you've got this patient, you can say, sorry, surgeon, I need you now because then you've got if you see something like that, the renal artery is acute has a problem, and then the surgeon has to be quick or the interventional radiologist.

Normally we talk to both, okay.

3D Ultrasound of the Transplant Kidney

What else can be done with the transplant kidney?

We can do 3D ultrasound of the transplant kidney.

When is it really helpful?

It's helpful if you have a surgeon who wants to understand what this where this lymphatic mass is waiting to be drained.

For example, this is a patient with lymphocele.

Some people show that it's not that interesting, and you can do power Doppler 3D you can see the renal the transplant renal artery.

This takes 10 seconds to be produced and with machines of several companies.

So I think it's really nice if you've got teaching purposes to do that.

New Features in Vascular Imaging

What are new features for vascular imaging of the transplant kidney?

And I have to admit, there's some new aspects and the firms are not sleeping, and this is very good.

And here you can see this is something called B flow, where you can this is B-mode differential imaging method.

It's not doppler based, where you can see the tiny vessels in the transplant kidney.

And this is another method where this is doppler based, where you also can see tiny vessels in the renal cortex, but be aware of the limitations.

With color doppler, you can see large vessels, you can see the macro perfusion.

If you really want to have a look at the micro perfusion, you always need contrast enhanced ultrasound.

That's a problem. But this is necessary, and I always get a little bit upset if my colleagues say in the morning, in the morning round, okay, the perfusion of the kidney is brilliant, and you can say which perfusion you performed.

Contrast enhanced ultrasound, no, we had a little look with our handheld pocket ultrasound machine, right?

Then you have to be careful to say that's really perfusion.

You can see the vascularization looks quite okay, but you don't have a clue about the real micro perfusion.

Contrast-Enhanced Ultrasound (CEUS) of the Transplant Kidney

Again, if you perform contrast enhanced ultrasound, you have to be aware of the nomenclature.

Same as with a normal kidney, cortical enhancement, medullary enhancement, late phase.

What is interesting in the contrast enhanced ultrasound of the transplant kidney, sometimes you've got additional vessels, and then you've got a little bit prolonged time.

So be aware that you have a look at the transplant kidney, not only in the cortical phase, but all phases to make sure that there's nothing going on in the meantime.

Guidelines and Quantitative Analysis

You have some guidelines.

We heard them very nicely this morning from the man of the guideline.

And we did a lot of they showed us some comments also on transplant kidney, perfusion abnormalities can be depicted absolutely right.

And the quantitative features, as I've shown you in my first lecture, they're a little bit well for people who do that very often, I think that transplant kidney is a very nice thing to be looked at with quantification, because you nearly have no breathing there.

And it's just it's very near to your transducer and it's a static thing.

So you can really think about doing that.

This is sometimes helpful, but this is also 2016, still a research field as the guideline pointed out.

Here you can see a transplant kidney, and we perform we add contrast enhanced ultrasound, and you can see the vascularization of the transplant is a little bit different to the kidney we've seen before.

So it's very slowly and it's a little bit less prominent here.

So you can see this kidney has a problem.

This is a kidney with rejection.

And then you can for example have a look at this time to peak curves, and you can see how long does it take to the peak perfusion in the renal cortex.

And you can have a look at the renal artery, at the renal cortex and can measure that time.

That's quite interesting. And it's quite reproducible. Yeah.

That was me. That was one of my students.

You can see you get an idea of what's going on, but you have to have several measurements to have a real reproducible, standardized thing.

So Tom Fisher from Berlin, he was very active working.

He's a hard worker on the transplant kidney.

He did that in 2008.

And he found out that the arrival time analysis might be helpful.

So he was measuring the arrival time.

One was the first bubble detected in the renal artery.

One was the first bubble detected in the renal cortex, and did an evaluation of that.

And interestingly, he found a gap between the normal population and the rejection.

And what he does he showed with quantitative ultrasound, you always have already seen with your own eyes, because if you've got a transplant kidney which is taking up the contrast media very quickly, you can say, spot on, great kidney.

You have a look at the lab findings you have, talk to the patient, everything's in the right order.

But if you've got a transplant kidney where the where the vessels are depicting like that, yeah, very very slowly.

And you can see, okay, it really takes time until the contrast media is going into this kidney.

Then you can see there's a problem.

And I normally just measure the time to peak by my own eyes.

It's also possible, and it's for clinical routine quite okay.

Case Reports

Swollen Transplant Kidney in a 60-Year-Old Woman

So some case reports, 60-year-old man a patient.

No, it was a woman with a swollen transplant kidney.

I remember that case. That was awful. It was her birthday.

And she said, I can't do my birthday party like that.

Yeah, I'm having pain.

I said, yes, but why do you come today?

And that one week before right, the surgeons in this room will ask for scalpels, right?

And let's have a look of what's going on.

If we perform ultrasound.

What we are used to do nowadays is we phone our surgeon and he says, okay, I come along.

And he's having a look right beside the patient in our ultrasound lab.

He's got the nice machines, he's got the experience about surgery.

So we put everything together and doing decision right with the patient in the ultrasound room.

This saves time and money.

And of course, we have a look, and can say, okay, this kidney is still so to say online, right?

It's the blood is going in everything. Okay?

So we take contrast enhance ultrasound to see the real extent of this infection, and to see whether this is only one fluid collection or several ones, as we've seen in the renal abscesses right now from our colleague, this was one big formation.

And our surgeons took this patient to operation theater, did a jet lavage and everything went well.

She had the only bad thing is it was her birthday inside the hospital, but we couldn't change that.

But the kidney could be saved.

Rising Creatinine Levels in a 44-Year-Old Patient

44-year-old patient with rising creatinine levels of the renal allograft.

Here you can see this is quite high.

Normal is till 1.2 though he was really dropping in with a rising creatinine levels.

The kidney looks not so nice.

It's 9.8 centimeters that in the well, that's still okay, but a little bit smaller than we are expected to have in transplant kidneys.

And if we have a look at contrast enhanced ultrasound, we can see that.

And have a look at this picture. What do you think?

You've got a bad feeling, right? Me too.

And you can see this is all necrosis.

Do we need to go ahead with CT scan, MRI, something like that?

Well, if we want to ruin the kidney completely, we should.

So there's no extra information we would get if we go on with these techniques.

So we performed biopsy and did plasmapheresis and did a follow up of this deceased kidney with a rejection and contrast enhanced ultrasound shot.

Not really an improvement of the situation.

So we try to stop this immunologic process.

But as you can see, there was not much to be rescued.

And yeah, the problem was we had to resect that kidney in the end, but for the follow-up, and if you've got these cases where you really fight, CEUS gives you the chance to get a real online and real time perfusion information of this deceased organ without sending it to hell.

By contrast enhanced CT, and this is really good.

Sometimes we win, sometimes we lose.

Post-Transplantation Necrosis in a 42-Year-Old Patient

This is 42-year-old patient three days after renal transplantation.

Typical situation, you want to go home and you get a call from the surgeon.

He says, alright, we need plasma for assistance.

This kidney is deceased.

This might have a rejection, do something, doctor.

And then we go on the ward with our machine and we have a look with contrast enhance ultrasound and receive that.

And what does this patient need?

Plasmapheresis, this patient needs a surgeon.

And based on that, we did right away the surgery, we don't lose any time.

And it was a completely necrosis after the section of the renal transplant artery.

So this is really a nightmare for the nephrologist that will see that, right?

Yeah, really get frightened.

If you see these crash glomeruli, it's really bad thing.

Delayed Graft Function and Hematoma in a 40-Year-Old Patient

So 40-year-old patient one day after renal transplantation, delayed graft function, people from our dialysis unit called us.

There's something going on.

I don't know, does he have a tumor or what's going on here?

So we first have a look that there's something going on.

Okay, what is it? Or is it hematoma?

Does it compress the kidney? Does it harm the kidney?

And we have a look. Does the surgeon have to remove that?

Maybe? And we can see with a higher frequency probe, even with a very old machine, okay.

Doesn't look so scary.

But again, we want to have a perfusion information and contrast enhanced ultrasound depicts the real size of the kidney and shows us that here's a hematoma, not only here.

If we go through the organ, we can see that there's some parts of this capsule are filled with hemorrhage and but it's not active bleeding as we've seen just before. It's just old hemorrhage.

And this recovered very well.

And we can see we can do a burst replenishment kinetic and can see this kidney's doing fine.

And after one more day, she started to have a sufficient urine production.

Everything went well.

Incidental Renal Mass in a 70-Year-Old Patient

This a 70-year-old patient with incidental finding of a renal mass in the transplant kidney.

That was a little bit frightening.

That was yeah, Paul, I was wondering as well, it was not so long time ago.

I've never seen that in that extent before that with the transplant kidney.

And so you can see this echo poor renal mass here.

It looks a little bit echoic if you take a higher frequency.

And we did a whole abdominal ultrasound. As always.

This patient also had splenic lesions, said, oh no contrast enhance ultrasound.

We see the perfusion, the mild perfusion of this tumor, but it's either or even a little bit hyper perfused in the end.

What would you do? First, we have to find out what's what is wrong with the spleen.

We had we punctured one of these spleen lesions.

It was a hemangioma. Thanks God.

So we had no problem with that.

So we asked our surgeon, you can see a washout due to shunting perfusion.

So I performed the ultrasound guided biopsy of this tumor.

You can see the needle. And we found out that it's a papillary carcinoma and then we resected it.

And it was a real clear cell carcinoma with papillary architecture that was interesting.

And it shows you the biopsy is no bad, but you have to see the whole tumor to get the real information about the tumor.

That's why we always happy to have the real information about the patient.

Post-Biopsy Aneurysm in a Young Patient

This was a young patient who has had a biopsy, several biopsies in Austria, and he had pain, and then he went back to hospital, and a very good interventional radiologist coiled the place where the biopsy had caused a little aneurysm.

And this guy was then in Munich and Kohler said, oh, I'm not doing well.

Said, come in and let's have a look.

You can see, well, that's another aneurysm again.

And if you add contrast, you can see the real extent of what's going on.

You can see the aneurysm.

And this was the old aneurysm, which was coiled, so we had another one, right?

What do we do? We call the interventional radiologist and say, do you like to do something?

And she said, no. Let's have a look at the moment here.

He will still wait.

And six weeks later, we had thrombosis of this aneurysm and everything went well, so to say.

So contrast enhanced ultrasound is also a good idea here for seeing for showing what's really going on.

Conclusion

So I want to conclude.

Ultrasound is a non-invasive first imaging tool after medical history, clinical exam, also available bedside.

And I think it's a great tool for people with a transplant.

Between a transplant, always step up the therapy, no contrast enhance ultrasound before the B-mode and the Doppler methods.

Be aware, Doppler ultrasound shows you the macro perfusion, and CEUS gives you a real idea about what's really going on.

I think it's a brilliant tool to have in nephrology.

And if you have a very good radiology department, I think it's a must have to avoid unnecessary treatments.

So I thank you very much.

It's our pathologist, our radiologist, our urologic surgeons.

And this is our conference again, and I want to encourage you to introduce these conferences in your home hospital if you don't have them yet.

Thank you very much for your kind attention.