Wilm’s Tumor

• Age: 80% <6yo; most common abdominal neoplasm 1-8 yo.
• Appearance: solid mass in kidney (claw sign), pushing away vessels, not crossing mid-line
• IVC and renal vein thrombosis
• Mets to lung, liver, brain, bone
• Staging
• I = confined to kidney
• II = local extension to perinephric space
• III = lymph nodes
• IV = distant mets
• V = bilateral renal
• DDx: neuroblastoma (crosses mid-line, encases vessels, calcify), multilocular cystic nephroma, sarcoma, RCC, nephroblastomatosis, mesoblastic nephroma, AML, renal medullary carcinoma

 

Renal Scintigraphy

MAG-3 or DTPA

• Perfusion/Obstruction
• normal uptake 50/50 L and R kidney; >60/40 is abnormal
• normal peak < 5 minutes
• normal residual coritcal activiy < 0.3
• Lasix
  • increases urine output
  • inject 15 min before MAG3/DTPA
  • no washout after Lasix = obstruction
  • normal T1/2 = < 10 min
  • obstructed T1/2 = >20 min
• Captopril
  • evaluate renal artery (renal artery stenosis, ischemia, renovascular hypertension)
  • baseline scan, captopril scan, post scan
  • high prob RVH = marked captopril induced changed

DMSA = Morphology

• for UTI or pyelonephritis, congenital malformation
• cold spots: pyelonnephritis, tumors, cyts, hydronephrosis, trauma, infarct

Radionuclide Cystogram

• UTI, VUR
• sulfur colloid, DTPA, MAG-3
• fill bladder until reverse flow

Source: ppt

Pediatric Renal Tumors

• Wilm’s tumor
• nephroblastomatosis
• Clear cell sarcoma
• Rhabdoid tumor
• Hamartoma
• Angiomyolipoma
• Ossifying Renal Tumor of Infancy
• Metanrphric Adenoma
• Adjacent Neuroblastoma from adrenal gland

Pediatric Cystic Renal Lesions

• Autosomal Recessive Polycystic Kidney Disease (ARKD)
• Multicystic Dysplastic Kidney (MCDK)
• Multilocular Cystic Nephroma (MLCN)

Decreased renal echogenicity

• Acute pyelonephritis
• Renal vein thrombosis
• Acute glomerulonephritis
• Lupus nephritis
• Lymphoma

Increased renal echogenicity

Cortical only:

• Acute/Chronic Glomerulonephritis
• Nephrosclerosis
• Acute tubular necrosis

Medullary only:

• Medullary nephrocalcinosis
• Renal pyramidal fibrosis

Cortical and Medullary:

• Chronic Plyeonephritis
• Chronic Glomerulonephritis

Patchy:

• Infection
• Scarring
• Renal Vein thrombosis

Big Kidneys Differential

Unilateral

• Compensatory hypertrophy
• Pyelonephritis
• Duplex kidney
• Renal Vein Thrombosis
• Hydronephrosis
• Acute renal infarct

Bilateral

• Unilateral cases as above
• AD PCKD
• AR PCKD
• Glomerulonephritis
• Acute tubular necrosis
• Diabetic nephropathy

In Kids:

• Nephroblastomatosis
• Nephrotic Syndrome
• Polycystic Kidney disease
• Glycogen Storage
• Lymphoma/Leukemia

Renal Laceration Grading

Grade 1

• hematuria, normal imaging
• contusion
• nonexpanding subcapsular hematomas

Grade 2

• nonexpanding perinephric hematoma confined to the retroperitoneum
• laceration <1cm deep, collecting system not involved

Grade 3

• laceration >1cm, collecting system not involved

Grade 4

• laceration extending to collecting system
• involve main renal artery or vein
• segmental infarctions without associated lacerations
• expanding subcapsular hematomas compressing kidney

Grade 5

• shattered or devascularized kidney
• ureteropelvic avulsions
• complete laceration or thrombus or main RA or V

Abnormal Renal Vasculature

• multiple renal arties is common, 25% of population
• second, diminutive artery supplying lower pole

• supernumerary veins, less common than arteries
• left is retroaortic

• significant for preop planning

Fibromuscular Dysplasia

• Medium to large artery vasculitis
• Most commonly affects renal arteries
• 15-20 yo females with refractory HTN
• MRA or arteriography: stenosis and post-stenotic dilitation, string or beads appearance.
• all layers affected: intima, media, adventitia

Grades of Ureteral Reflux

Grade	Findings
I	Reflux confined to ureter only
II	Reflux to the level of the intrarenal collecting system without dilatation
III	Grade II + mild or moderate dilatation of the ureter or renal pelvis, but no or only slight forniceal blunting
IV	Grade II + calyceal dilatation and obliteration of the sharp angle of the fornices, but maintainance of the papillary impressions
V	Gross dilatation and tortuosity of the ureter; gross dilatation of the renal pelvis and calices; papillary impressions are no longer visible

Grades I-III: Typically resolve as the child grows

Grades IV-V: Typically require surgery to correct

http://www.auntminnie.com/index.asp?sec=ref&sub=ncm&pag=get&itemid=54506

Renal Function and Iodinated Contrast

Prevent contrast induced nephropathy.

• Hold metformin prior and 2 days after
• Hold diuretics 1 day prior
• hydrate with IV normal saline
• Mucomyst 1200mg IV prior to CT or 600mg PO BID before and after scan, or…
• Bicarb 3ml/kg/hr x 1hr prior and 1ml/kg/hr x 6hrs afterwards (mix 3 amps in 1L of D5 water, bolus 500cc prior to ct, then 100cc per hour until its gone)

Cr less than 1.4 = full dose contrast
Cr 1.5-2.0 = do above.
Cr greater than 2.0 = consider alternative test

ALL patients over 40 years old require BUN and Creatinine check prior to getting IV contrast.

Bosniak CT Classification of Cystic Masses

I = simple cyst; nonoperative

II = septated, minimal calcium, nonenhancing high-density cysts, infected cysts; nonoperative

III = multiloculated, hemorrhagic, dense calcification, non-enhancing solid component; renal-sparing component

IV = marginal irregularity, enhancing solid component; Radical nephrectomy

Renal Masses

see differentials for solid and cystic renal masses.

Solitary Expansile Masses

• Cystic Lesions
• Renal Cell Carcinoma
• Oncocytoma
• Multilocular Cystic Nephroma
• Renal Abscess
• Focal XGP
• Renal Metastasis
• Angiomyolipoma

Multiple Expansile Masses

• Polycystic Kidney Disease
• Medullary Cystic Disease
• Juvenile Nephronophthisis
• von Hippel-Lindau Disease
• Acquired Cystic Disease of Dialysis
• multiple RCC (2% of RCC)
• metastasis (colon)
• lymphoma
• multiple abscesses
• multiple oncocytomas (central stellate scar)

Geographic Infiltrating Masses

• Transitional Cell Carcinoma
• Squamous Cell Carcinoma
• Renal Medullary Carcinoma (invade renal sinus, African Americans)
• Collecting Duct Carcinomas
• Lymphoma and Metastasis
• Pyelonephritis
• renal tuberculosis
• XGP
• Renal Infarction

Subcapsular Renal Hematoma

• subcapsular mass with effacement of renal parenchyma
• resorbed and calcifies with time, forms pseudocapsule
• complication: Page Kidney (ischemia, HTN, renin release)

http://brighamrad.harvard.edu/Cases/bwh/hcache/127/full.html

Retroperitoneal Hemorrhage

Spontaneous: Sudden onset flank pain. Surgery is indicated if etiology not determined by imaging. Do f/u CT in 3-6 month if source of bleed indeterminate.

• Renal tumor (malignant and benign)
• Vascular: ruptured renal artery aneurysm, vasculitis, AVM, segmental renal infarction
• Inflammation/Infection: abscess, nephritis
• Coagulopathy
• Adrenal Tumor: pheochromocytoma, pseudocyst, leylolipoma, hemangioma, adenoma, met

Trauma – 3 retroperitoneal zones:

Compartments and Planes:

See Retroperitoneal Structures.

Resistive Index on Renal Doppler

Normal RI <0.70.

• renal medical disease (vascular/tubulointerstitial process >> glomerular disease)
• significant systemic hypotension
• markedly decreased HR
• perinephric or subcapsular fluid collections
• neonate and infants

Tuberous Sclerosis

• Autosomal dominant neuroectodermal disorder characterized by multifocal systemic hamartomas and malformation
• 30% dead by age 5, 75% dead by age 20
• affects CNS, kidney, lung, skin, heart
• Triad: zits, fits, nitwits (facial angiofibroma, epileptic seizures, MR)
• chromosome 9 and 16
• Diagnostic criteria: 2 major or 1 major + 2 minor

Major

• cortical/subcortical involvement
• subependymal giant cell astrocytoma
• cardiac rhabdomyoma
• facial angiofibroma
• retinal hamartomas
• renal angiomyolipoma
• Shagreen patches
• Ash-leaf spots
• Lymphanioleiomyomatosis

Minor

• gingival fibroma
• dental pits
• hamartomatous rectal polyps
• renal cysts
• cerebral WM migration lines
• Confetti skin lesions
• bone cysts

CNS involement

• subependymal hamartomas
• giant cell astrocytoma
• cortical/subcortical tubers
• heterotopic gray matter islands in white matter

Skin involvement

• facial angiofibromas
• Shagreen rouch skin patches = “pigskin”
• ash leaf patches
• ungual fibromas
• cafe-au-lait spots

Occular involvement

• phakoma

Renal Involvement

• angiomyolipoma
• multiple cysts
• renal cell carcinoma

Other

• lung: progressive respiratory insufficiency
• heart: cardiomyopathy, rhabdomyoma of ventricle or atrium, aortic aneurysm
• bone: bone islands, periosteal thickening, bone cysts
• adenomas of liver, pancreas, spleen
• vascular: aortic aneurysms

Renal angiogram and embolization Dictation

Radiologists: [x]

Clinical History: [x]

Technique and findings:

After obtaining informed consent, the patient was placed supine on the angiography table. The right groin was prepped and draped in a sterile fashion. Following the administration of lidocaine , the right common femoral artery was accessed using a 19 gauge needle. A Bentson wire was threaded into the abdominal aorta. The needle was removed and a 5 French sheath was placed into the right common femoral artery.

Through the sheath, a 4 French omni flush catheter was threaded over the wire into the upper abdominal aorta. An aortogram was performed.

The catheter was removed and a Cobra catheter was then used to cannulate the left renal artery and an angiogram was obtained.

A Renegade high flow catheter was then advanced into multiple branches of the left kidney, where 4 cc’s of Embospheres 700-900 micron and 2 vials of Contour 700-900 micron to complete stasis. Three 8 mm coils were then placed in the mid left renal artery. Post embolization angiogram demonstrates no flow to the left kidney.

The splenic artery was then selectively catheterized and an angiogram demonstrates the splenic artery to be displaced superiorly, with no branches feeding the left upper pole mass.

A flush catheter was then re-advanced into the upper abdominal aorta and repeat aortogram was performed.

The catheter and sheath were removed and pressure was applied to the right groin until hemostasis was achieved. A sterile dressing was applied.

Dr. [x], the attending interventional radiologist, was present for the critical portions of the procedure and reviewed all images obtained.

Medications: Fentanyl [x] ug IV, Versed [x] mg IV, Ancef [x] g IV

Contrast: [x] cc of Omni 300.

Impression:

Large mass in the left kidney, successfully embolized as described above. No flow is seen towards the left kidney on repeat angiogram.

Nephrostogram and exchange of PCN for nephroureteral stent Dictation

Procedure: [x]

1. [Left] nephrostogram .

2. Exchange of [left] PCN for [left] nephroureteral stent .

Radiologists: [x]

History: [x]

Technique:

Informed consent was obtained. The patient was identified and placed prone in the angiographic table. The left flank and left percutaneous nephrostomy tube were prepped and draped in the usual sterile fashion.

Contrast was injected through the existing left percutaneous nephrostomy and a nephrostogram was obtained, which demonstrated a left distal ureteral stricture. A guidewire was advanced into the left renal pelvis and the catheter was exchanged over a wire. A Bernstein catheter was advanced into the left renal pelvis and a slightly guidewire access was obtained into the bladder. A new 26 cm long 8 French nephroureteral stent was then advanced into the bladder. Contrast injection onfirms the catheter position with its distal tip of the bladder and the proximal end coiled within the left renal pelvis.

The catheter was sutured to the patient’s skin and sterile dressing was applied. The catheter was connected to a leg bag.

Dr. [x], the attending interventional radiologist, was present for the critical portions of the procedure and reviewed all images obtained.

Impression:

Successful replacement of the left PCN for a left 26 cm long 8 French nephroureteral stent .