Evaluation of Doppler ultrasound for renal transplant evaluation for - PowerPoint PPT Presentation

Evaluation of Doppler ultrasound for renal transplant evaluation for renal transplant evaluation ARRS meeting 2011 ‐ 05 ‐ 03 F Edward Boas, Terry Desser and Aya Kamaya Terry Desser, and Aya Kamaya Stanford Hospital

Disclosure of commercial interest Disclosure of commercial interest Neither I nor my immediate family members Neither I nor my immediate family members have a financial relationship with a commercial organization that may have a commercial organization that may have a direct or indirect interest in the content.

Diagnoses Diagnoses Diagnosis Number of patients 1. Normal, with creatinine ≤ 1.5 7 2. Delayed graft function post ‐ operatively 6 3 Acute rejection 3. Acute rejection 8 8 4. Chronic rejection, transplant 5 glomerulopathy, or drug toxicity, creatinine > 1.5 i i 1 5 5. Hydronephrosis 5 6. Renal vein thrombosis 2 7. Other 14 Total 47

Resistive index = ( V Resistive index ( V max V min )/ V max – V i )/ V y ow velocit Fl V V max V V min i Time

Resistive index Resistive index Sensitivity 38% for acute rejection Specificity 63% 40% Normal (0.71 ± 0.11) 35% Acute rejection (0.77 ± 0.11) Other 30% 30% 25% 20% Acute rejection 15% Delayed graft function 10% Renal vein thrombosis 5% 0% <0.7 <0.7 0.70 – 0.79 0.70 0.79 0.80 0.89 0.80 – 0.89 0.90 0.99 0.90 – 0.99 ≥ 1 ≥ 1 Resistive index

Mid renal artery velocity waveform Mid renal artery velocity waveform

Velocity waveforms Velocity waveforms 30 — Normal 25 w (ml/s) — Acute rejection 20 artery flow 15 15 10 5 Renal 0 0 0.2 0.4 0.6 0.8 1 ‐ 5 ‐ 10 10 Fraction of cardiac cycle

Velocity waveforms Velocity waveforms 30 — Normal 25 w (ml/s) — Acute rejection 20 — Delayed graft function — Chronic rejection Chronic rejection artery flow 15 15 — Hydronephrosis 10 — Renal vein thrombosis — Other 5 Renal 0 0 0.2 0.4 0.6 0.8 1 ‐ 5 ‐ 10 10 Fraction of cardiac cycle

Velocity waveforms (average) Velocity waveforms (average) 20 15 Normal ml/s) tery flow (m 10 Acute rejection 5 in renal art 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Mai ‐ 5 Renal vein thrombosis ‐ 10 Fraction of cardiac cycle

Velocity waveforms (Average ± stdev) Velocity waveforms (Average ± stdev) 20 Thick lines: average Thick lines: average Thin lines: one standard deviation 15 Normal ml/s) tery flow (m 10 Acute rejection 5 in renal art 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Mai ‐ 5 Renal vein thrombosis ‐ 10 Fraction of cardiac cycle

Windkessel model Windkessel model Systole l Pulsatile pump Continuous capillary flow Image credits: Piotr Micha ł Jaworski (kidney) and User ZooFari on Wikipedia (heart). Creative Commons Attribution ‐ Share Alike 3.0 Unported license.

Windkessel model Windkessel model Systole l Pulsatile pump Continuous capillary flow Image credits: Piotr Micha ł Jaworski (kidney) and User ZooFari on Wikipedia (heart). Creative Commons Attribution ‐ Share Alike 3.0 Unported license.

Windkessel model Windkessel model Systole l Pulsatile pump Continuous capillary flow Image credits: Piotr Micha ł Jaworski (kidney) and User ZooFari on Wikipedia (heart). Creative Commons Attribution ‐ Share Alike 3.0 Unported license.

Windkessel model Windkessel model Diastole l Pulsatile pump Continuous capillary flow Image credits: Piotr Micha ł Jaworski (kidney) and User ZooFari on Wikipedia (heart). Creative Commons Attribution ‐ Share Alike 3.0 Unported license.

Windkessel model Windkessel model Diastole l Pulsatile pump Continuous capillary flow Image credits: Piotr Micha ł Jaworski (kidney) and User ZooFari on Wikipedia (heart). Creative Commons Attribution ‐ Share Alike 3.0 Unported license.

Windkessel model Windkessel model Diastole l Pulsatile pump Continuous capillary flow Image credits: Piotr Micha ł Jaworski (kidney) and User ZooFari on Wikipedia (heart). Creative Commons Attribution ‐ Share Alike 3.0 Unported license.

3 ‐ element Windkessel model 3 element Windkessel model R 1 Pre ‐ glomerular resistance (renal artery) C Vascular compliance R 2 Post ‐ glomerular resistance (renal vein)

3 ‐ element Windkessel model 3 element Windkessel model

Normal Normal

High R 1 High R 1

Normal Normal

High R 2 High R 2

Normal Normal

Low C Low C

3 ‐ element Windkessel model 250 7 6 200 5 150 4 R 2 2 C C 3 100 2 50 1 0 0 0 10 20 30 0 10 20 30 R 1 R 1 7 � Normal 6 � Acute rejection 5 � Delayed graft function 4 � Chronic rejection � Chronic rejection C � Hydronephrosis 3 � Renal vein thrombosis 2 � Other 1 0 0 50 100 150 200 250 R 2

3 ‐ element Windkessel model 250 7 6 200 5 Renal vein thrombosis 150 4 R 2 2 C C 3 100 2 50 1 0 0 0 10 20 30 0 10 20 30 R 1 R 1 7 � Normal 6 � Acute rejection 5 � Delayed graft function 4 � Chronic rejection � Chronic rejection C � Hydronephrosis 3 � Renal vein thrombosis 2 � Other 1 0 0 50 100 150 200 250 R 2

Doppler ultrasound Doppler ultrasound Acute rejection can’t be diagnosed using: Acute rejection can t be diagnosed using: • resistive index (intra ‐ renal) • pre ‐ glomerular resistance l l i • post ‐ glomerular resistance • vascular compliance • the shape of the velocity waveform (mid renal the shape of the velocity waveform (mid renal artery)

Conclusions Conclusions • Doppler ultrasound of kidney transplants has Doppler ultrasound of kidney transplants has limited value in diagnosing acute rejection. • Resistive index > 0 9 is seen in acute rejection • Resistive index > 0.9 is seen in acute rejection, delayed graft function, and renal vein thrombosis. thrombosis • The 3 ‐ element Windkessel model can be used to determine vascular resistance and d i l i d compliance.

Additional slides Additional slides

3 ‐ element Windkessel model 3 element Windkessel model Resistive index is increased with: Resistive index is increased with: • Increased R 2 (post ‐ glomerular resistance) • Decreased R 1 (pre ‐ glomerular resistance) d ( l l i ) • Increased C (vascular compliance) • Increased pulse pressure • Increased heart rate Increased heart rate

Principal component analysis Principal component analysis Average waveform Average waveform Principal components Principal components 12 0.25 Flow 0.2 Biphasic pulsatility 10 Triphasic pulsatility 0.15 w (ml/s) ml/s) 0.1 8 0.05 Flow (m 6 6 Flow 0 0 0.2 0.4 0.6 0.8 1 ‐ 0.05 4 ‐ 0.1 2 ‐ 0.15 ‐ 0.2 0 0 0.2 0.4 0.6 0.8 1 ‐ 0.25 Fraction of cardiac cycle Fraction of cardiac cycle

Principal component analysis 70 20 60 15 ulsatility lsatility 50 10 40 5 30 0 riphasic pu Biphasic pu ‐ 50 0 50 100 20 ‐ 5 10 ‐ 10 0 ‐ 15 ‐ 50 0 50 100 ‐ 10 ‐ 20 Tr B ‐ 20 ‐ 25 ‐ 30 ‐ 30 Flow Flow 20 20 � Normal 15 ulsatility � Acute rejection 10 � Delayed graft function 5 0 � Chronic rejection � Chronic rejection Triphasic pu ‐ 50 0 50 100 ‐ 5 � Hydronephrosis ‐ 10 � Renal vein thrombosis ‐ 15 � Other ‐ 20 ‐ 25 25 T ‐ 30 Biphasic pulsatility