Imaging Patients with Kidney Failure

Mary Jennings Clingan, MD • Zhao Zhang, DO • Melanie P. Caserta, MD • Kelly L. Cox, DO • Vivek Gupta, MD • Deborah A. Baumgarten, MD
Qihui (Jim) Zhai, MD • Lauren F. Alexander, MD
Author affiliations, funding, and conflicts of interest are listed at the end of this article.

The approach to imaging a patient with kidney failure continues to evolve. Overstatement of the risk of iodinated contrast ma-
terial–induced (ie, contrast-induced) acute kidney injury and new guidelines for administration of gadolinium-based contrast
media affect screening and the choice of contrast material. Treatment of kidney failure requires dialysis or a kidney transplant.
Pretransplant imaging includes assessment for the feasibility of performing a transplant and evaluation for underlying malignancy
and peripheral vascular disease. Patients with kidney failure are at high risk for renal cell carcinoma. Subtypes that occur exclu-
sively or more commonly in patients with kidney failure, such as acquired cystic kidney disease, renal cell carcinoma, and clear cell
papillary renal cell carcinoma, have specific clinical-pathologic characteristics, with indolent behavior. Performing US for dialysis
planning increases the success of placement of an arteriovenous fistula, while postoperative US evaluation is essential in assess-
ment of access dysfunction. Systemic manifestations in patients with kidney failure are multifactorial and may relate to the under-
lying cause of renal failure or may be secondary to treatment effects. Disturbances in mineral and bone metabolism and soft-tissue
and vascular calcifications are seen in patients with chronic kidney disease and mineral bone disorder. Neurologic and cardiotho-
racic complications are also common. The authors provide a comprehensive overview of imaging considerations for patients with
kidney failure, including the appropriate use of CT, MRI, and US with their respective contrast agents; the use of imaging in trans-
plant workup and dialysis assessment; and the common renal and extrarenal manifestations of kidney failure.
©
RSNA, 2023 • radiographics.rsna.org

GENITOURINARY IMAGING
This copy is for personal
use only. To order copies,
contact reprints@rsna.org
May 2023 Clingan et al

ing, and contrast-enhanced US for problem solving are dis-

Supplemental RadioGraphics 2023; 43(5):e220116
https://doi.org/10.1148/rg.220116 cussed, with an emphasis on renal tumors and vasculature.
Material We cover imaging for hemodialysis access, maturation crite-
Content Codes: CT, GU, MR, US
Quiz questions for this Abbreviations: ACKD = acquired cystic kid- ria, and assessment of complications, including those of peri-
article are available ney disease, ACR = American College of Ra- toneal dialysis. Because kidney failure affects more than just
in the supplemental diology, AVF = arteriovenous fistula, AVG =
material. arteriovenous graft, eGFR = estimated
the kidneys, commonly encountered systemic manifestations
glomerular filtration rate, GBCM = gadolin- involving the musculoskeletal, neurologic, and cardiothoracic
ium-based contrast media, KDIGO = Kid- systems are also reviewed.
ney Disease Improving Global Outcomes,
KDOQI = Kidney Disease Outcomes Quality
Initiative, NKF = National Kidney Foundation, Contrast Media Guidelines, Screening, and
RCC = renal cell carcinoma
Prophylaxis
TEACHING POINTS Iodinated Contrast Media
„ Patients with acute kidney injury or stage 4 or 5 chronic kidney disease who The risk of acute kidney injury from the use of iodinated con-
are not undergoing dialysis have a relative (but not absolute) contraindica- trast material at CT has been overstated because of a historic
tion for iodinated contrast media, and when it is required for diagnosis of
lack of control groups to separate contrast material–induced
life-threatening conditions, its use should not be withheld.
(ie, contrast-induced) acute kidney injury from contrast-asso-
„ Because the risk of nephrogenic systemic fibrosis with a standard dose of
group II GBCM is so low, the potential harm of delaying or withholding it in
ciated acute kidney injury, which is a correlative diagnosis (5–
patients with acute kidney injury or an eGFR of less than 30 mL/min per 1.73 7). The most important risk factor for contrast-induced acute
m2 is likely to outweigh the risk of its use for indicated examinations. kidney injury is preexisting severe renal insufficiency, and the
„ Two distinct RCC subtypes occurring more frequently or exclusively in pa- calculated eGFR is more accurate than the serum creatinine
tients with kidney failure have been described in studies during the past de- level and is a better marker of the risk of contrast-induced
cade: ACKD-associated RCC and clear cell papillary RCC. acute kidney injury (5,6). New eGFR equations that are not
„ The ratio criteria for hemodialysis access stenosis differ according to location: based on the patient’s race but instead incorporate creatinine
3:1 for juxta-anastomotic stenosis and 2:1 for draining vein, central vein, and
and cystatin C levels are more accurate and lead to smaller
feeding artery stenosis.
differences in eGFR between races (7). Currently there is little
„ In addition to bone changes, patients with kidney failure are predisposed
evidence that intravenous iodinated contrast media is an in-
to extraskeletal manifestations for which KDIGO has proposed the broader
term, chronic kidney disease mineral bone disorder, to reflect disturbances dependent risk factor for acute kidney injury in patients with
in mineral and bone metabolism as well as soft-tissue and vascular calcifi- an eGFR greater than 30 mL/min per 1.73 m2 (5).
cations. Patients with acute kidney injury or an eGFR of less than
0 mL/min per 1.73 m2 should prompt discussion between
radiologists and referring professionals about the risks and
benefits of iodinated contrast media. Recommendations for
Introduction screening and prophylaxis and important considerations from
Chronic kidney disease affects approximately 15% of adults a consensus statement from the American College of Radiol-
in the United States or nearly 37 million people (1). The Kid- ogy (ACR) and the National Kidney Foundation (NKF) for the
ney Disease Improving Global Outcomes (KDIGO) practice use of intravenous iodinated contrast media in patients with
guidelines define chronic kidney disease as abnormalities in kidney disease are summarized in Figure 1 (5). Patients with
kidney structure or function that are present for greater than 3 acute kidney injury or stage 4 or 5 chronic kidney disease who
months, with health implications, which can be classified on are not undergoing dialysis have a relative (but not absolute)
the basis of cause, albuminuria category, or estimated glomer- contraindication for iodinated contrast media, and when it is
ular filtration rate (eGFR). Radiologists are most interested in required for diagnosis of life-threatening conditions, its use
the imaging implications for patients with stage 4 (eGFR < should not be withheld. Volume expansion with normal sa-
30 mL/min per 1.73 m2) and stage 5 (eGFR < 15 mL/min per line solution is indicated as prophylaxis for contrast-induced
1.73 m2) chronic kidney disease, with stage 5 considered kid- acute kidney injury in patients with an eGFR of less than 30
ney failure (2,3). KDIGO defines acute kidney injury as an in- mL/min per 1.73 m2 who are not undergoing maintenance
crease in a patient’s serum creatinine level of greater than or dialysis if there are no contraindications (5). There is no in-
equal to 0.3 mg/dL within 48 hours or of greater than or equal dication to initiate or change dialysis on the basis of the ad-
to 1.5 times the baseline known or presumed level within the ministration of iodinated contrast media, regardless of renal
prior 7 days, or a urine volume of less than 0.5 mL per kilo- function. Standard contrast material dosing is recommended,
gram per hour for 6 hours (4). because a reduced dose may result in suboptimal images (5,6).
Renal function may influence both why and how a patient If a patient is undergoing dialysis and is experiencing anu-
may be imaged. The radiologist should be aware of imaging ria, iodinated contrast media may be used without concern.
findings that are specific to patients with kidney failure. This A patient who is undergoing dialysis and making urine has
article serves as a broad review of imaging in patients with a theoretical risk for further loss of residual renal function.
kidney failure, starting with new guidelines for contrast ma- The ACR and NKF recommend treating these patients as
terial and recommendations for screening and prophylaxis. they would treat those with acute kidney injury or an eGFR
Renal manifestations of kidney failure, pretransplant imag- of less than 30 mL/min per 1.73 m2 who are not undergoing

Volume 43 Number 5 2 radiographics.rsna.org

May 2023 Clingan et al

Figure 1. Screening, prophylaxis recommendations, and important considerations from a consensus statement from the American College of Radiology
(ACR) and the National Kidney Foundation (NKF) for the use of intravenous iodinated contrast media in patients with kidney disease (5). AKI = acute kidney
injury, CEUS = contrast-enhanced US, CHF = congestive heart failure, CKD = chronic kidney disease, eGFR = estimated glomerular filtration rate, ER = emer-
gency room, hr = hour, NS = normal saline.

dialysis. However, authors of a recent systematic review and function is now optional before administration of a group
meta-analysis (8) found that iodinated contrast media may II agent (6). Few if any unconfounded cases of nephrogenic
not result in a significant reduction of residual function in systemic fibrosis have been reported with Group III agents,
patients undergoing dialysis, prompting the Canadian Asso- but data are limited and kidney function screening remains
ciation of Radiologists to conclude that the presence of urine necessary (6). Recommendations for screening, and import-
output in patients undergoing dialysis should not influence ant considerations from consensus statements from the ACR
the use of iodinated contrast media (9). and the NKF for the use of GBCM in patients with kidney
disease are summarized in Figure 2 (10).
Gadolinium-based Contrast Media No prophylaxis reduces the risk of nephrogenic systemic fi-
Gadolinium-based contrast media (GBCM) are categorized brosis. For patients undergoing dialysis, group II GBCM must
into three groups (Fig 2) on the basis of risk of or association be used and attempts can be made to coordinate the MRI ex-
with nephrogenic systemic fibrosis. Nephrogenic systemic amination before regularly scheduled postexamination dial-
fibrosis is a systemic disease characterized by fibrosis of the ysis. Otherwise, dialysis should not be initiated or altered on
skin and other tissues that is triggered by exposure to GBCM the basis of administration of group II or III GBCM (10).
and occurs almost exclusively in patients with acute kidney
injury or an eGFR of less than 30 mL/min per 1.73 m2 (6,10). Primary Manifestations of Kidney Failure
Nearly all unconfounded cases of nephrogenic systemic fi-
brosis were linked to Group I agents, which are now contra- Acquired Cystic Kidney Disease
indicated for use in patients at risk for nephrogenic systemic The longer patients are undergoing dialysis, the more likely
fibrosis (6,10). Because the risk of nephrogenic systemic they are to develop acquired cystic kidney disease (ACKD),
fibrosis with a standard dose of group II GBCM is so low, which is reported in 10%–20% of patients after 1–3 years and
the potential harm of delaying or withholding it in patients more than 90% of patients after 5–10 years of dialysis (12).
with acute kidney injury or an eGFR of less than 30 mL/ Imaging findings include normally sized or atrophic kidneys
min per 1.73 m2 is likely to outweigh the risk of its use for with multiple small cysts of varying complexity, regardless of
indicated examinations (10). Authors of a 2020 systematic the initial cause of renal failure or the method of dialysis. The
review and meta-analysis (11) showed 0 events after 4931 incidence of renal cell carcinoma (RCC) is threefold to 24-fold
administrations of group II GBCM to patients with an eGFR higher in patients with kidney failure than it is in the general
of less than 30 mL/min per 1.73 m2. Assessment of kidney population (13), and patients with ACKD have more than a
Volume 43 Number 5 3 radiographics.rsna.org
May 2023 Clingan et al

Figure 2. Screening recommendations and important considerations from a consensus statement from the ACR and the NKF for the use of GBCM in pa-
tients with kidney disease (5). AKI = acute kidney injury, CKD = chronic kidney disease, ED = emergency department, NSF = nephrogenic systemic fibrosis.

100-fold increased risk (14), so each lesion warrants careful and is the fourth most common RCC subtype after clear cell
evaluation to distinguish among simple cysts, cystic renal RCC, papillary RCC, and chromophobe RCC (13). Clear cell
masses, and solid masses. Noncontrast CT is frequently per- papillary RCC is characterized by cuboidal to columnar clear
formed in patients with renal disease, and any heterogeneous cells, with a tubulopapillary arrangement and horizontally
lesion or a focal kidney lesion measuring more than 20 HU or aligned nuclei, with inverse polarity, and shows at least fo-
less than 70 HU is indeterminate and warrants further evalu- cal papillary architecture (Fig S2) (16). Two imaging patterns
ation (15). Contrast-enhanced US is an alternative to GBCM have been described with clear cell papillary RCC: (a) solid
or iodinated contrast media in this patient population (Fig 3). heterogeneous tumors with minor cystic changes and rare
calcification, which show T2 hyperintensity, arterial enhance-
Kidney Tumors ment, and delayed washout similar to the appearance of clear
All major RCC subtypes have been reported in patients with cell RCC (Fig 5) or (b) cystic clear cell papillary RCC with a
kidney failure to include a higher percentage of papillary RCC predominantly unilocular pattern often classified as Bosniak
and chromophobe RCC (16). Two distinct RCC subtypes oc- III or IV (17) (Fig 6). Clear cell papillary RCC demonstrates
curring more frequently or exclusively in patients with kidney indolent behavior, with no recurrences or metastatic disease
failure have been described (13,16) in studies during the past reported to date (13).
decade: ACKD-associated RCC and clear cell papillary RCC. Anastomosing hemangiomas of the kidney are rare be-
ACKD-RCC is specific to patients with kidney failure and may nign vascular tumors that are seen mostly in patients with
occur in a cyst in a background of multiple cysts. ACKD-RCC kidney failure. They are small (<2 cm) and composed of si-
can be multifocal or bilateral and is usually low grade with nusoidal capillary-sized vessels lined by flat or hobnail en-
indolent biologic behavior, although sarcomatoid and rhab- dothelial cells (13). An anastomosing hemangioma of the
doid features have been described (16). ACKD-RCC has tu- kidney occurs in the medulla, often abuts the kidney sinus
mor cells with abundant eosinophilic or a clear cytoplasm and fat, and demonstrates arterial enhancement indistinguish-
prominent nucleoli with a sievelike appearance secondary to able from RCC (13).
cytoplasmic or intracellular vacuolation and characteristic in- Although long-term (>20 years) hemodialysis has been as-
tratumoral calcium oxalate crystals (Fig S1) (16). CT features sociated as an unfavorable prognostic factor for RCC because
of ACKD-RCC have been described as rounded, well-defined, of the potential for sarcomatoid transformation, patients with
and often exophytic lesions that are commonly isoattenuating RCC and kidney failure have a favorable overall prognosis
on noncontrast CT images and can be solid, cystic, or mixed (13,18) likely because of the indolent histopathologic charac-
in attenuation on contrast-enhanced CT images (Fig 4) (14). teristics of kidney failure–associated RCC and the likelihood of
Clear cell papillary RCC has been reported in patients with early diagnosis. The risk of recurrent RCC in patients with kid-
kidney failure or ACKD, but it also can occur sporadically ney failure is lower than that in the general population, which
Volume 43 Number 5 4 radiographics.rsna.org
May 2023 Clingan et al

Figure 3. Suspected papillary renal cell carcinoma (RCC) in a 57-year-old man who un-
derwent CT evaluation for a kidney transplant. (A) Coronal noncontrast CT image shows an
indeterminate mass (arrow) in the upper pole of the right kidney, with attenuation of 34 HU.
(B) Transverse color Doppler US image shows that the lesion (arrow) is hypoechoic with
low-level internal echoes, possibly a solid component, but without vascularity. (C) Trans-
verse contrast-enhanced US images show homogeneous hypoenhancement of the mass
(arrow) relative to the kidney parenchyma. Papillary RCC was confirmed at surgery.

Figure 4. Kidney failure and acquired cystic kidney dis-

ease (ACKD) in a 60-year-old man who underwent hemo-
dialysis for 4 years and presented for kidney transplant
workup. (A) Axial contrast-enhanced CT image shows an
indeterminate heterogeneous mass (arrow) in the right up-
per pole of the kidney, with attenuation of up to 32 HU. (B) Transverse contrast-enhanced US image shows enhancing thickened and nodular septa, which
were not well appreciated at CT. Surgical pathologic results showed ACKD-associated RCC.

is important for patients in whom a kidney mass is discovered imaging is more likely to be ordered for patients older than
while awaiting transplant (18). 50 years, those with diabetes or hypertension as the cause of
chronic kidney disease, and those with known atherosclerosis
Imaging in Patients with Kidney Failure such as ischemic heart disease or peripheral vascular disease
(19).
Pretransplant Imaging Evaluation of the external iliac arteries and their inflow
Imaging may be requested for a potential kidney transplant re- for peripheral vascular disease guides surgical planning, be-
cipient before surgery. Typically, noncontrast CT is performed cause detection of peripheral vascular disease in patients with
to assess the technical feasibility of a transplant, evaluate for kidney failure is associated with worse patient and allograft
peripheral vascular disease, and detect coexisting conditions survival (20). Heterotopic transplants usually involve the ex-
that would change patient treatment, such as renal stones, ternal iliac arteries, and surgeons need an arterial segment of
infection, or an underlying malignancy (19). Pretransplant at least 3 cm, without calcifications (19). Peripheral vascular

Volume 43 Number 5 5 radiographics.rsna.org

May 2023 Clingan et al

Figure 5. Kidney failure and clear cell papillary RCC in a

58-year-old man who had undergone peritoneal dialysis for 6 years and presented for pretransplant evaluation. (A) Axial noncontrast CT image shows a sol-
id-appearing indeterminate mass that is exophytic from the mid left kidney (arrow), with attenuation of 38 HU. (B) Longitudinal contrast-enhanced US image
shows a solid homogeneous enhancing mass (arrow) that is concerning for RCC. Subsequent nephrectomy showed clear cell papillary RCC.

Figure 6. Kidney failure and ACKD in a 76-year-old

man who had undergone hemodialysis for 3 years
and presented for pretransplant evaluation. (A) Axial
noncontrast CT image shows a solid-appearing nodule
(arrow) with attenuation of 54 HU in a larger fluid-atten-
uating cyst in the right kidney (*). (B) Transverse con-
trast-enhanced US image shows enhancement of a mural nodule (arrow) in a cystic mass in the upper pole of the right kidney that is concerning for cystic
RCC. The patient subsequently underwent right nephrectomy, with surgical pathologic results showing clear cell papillary RCC.

disease involving the external iliac arteries can lead to renal Contrast-enhanced US for Problem Solving in
artery stenosis of the allograft, hypertension, and graft fail- Kidney Failure
ure (20). The degree of calcification involving the common Incidental detection of indeterminate lesions in patients with
iliac arteries and external iliac arteries is often subjectively as- kidney disease is common. Traditionally, contrast-enhanced
sessed as mild, moderate, or severe, if present. However, scor- CT or contrast-enhanced MRI examinations are performed for
ing systems have been described (21). In a 2021 study (21) of a further characterization of the kidneys. However, patients and
simplified iliac artery calcium scoring system to guide periop- providers may be hesitant to use GBCM or iodinated contrast
erative management for renal transplant, the investigators media, despite the evolving guidelines. Contrast-enhanced US
found that patients with severe plaque in the external iliac is an excellent alternative modality to contrast-enhanced CT
arteries were significantly more likely to require intraopera- and contrast-enhanced MRI for patients with kidney failure.
tive arterial reconstruction and postoperative amputation of Off-label use of US contrast agents for renal examination has
the lower extremity, whereas plaque burden in the common been evaluated in published studies (23–27), and the contrast
iliac arteries was associated with major postoperative adverse agents are listed in Table 1. US contrast agents have no neph-
cardiac events (21). rotoxicity, making them safe for patients with kidney failure.
The right iliac fossa is preferred for renal transplant, given Additional advantages of contrast-enhanced US include the
the shorter renal vein graft (22). Preoperative imaging should absence of ionizing radiation, portability, high sensitivity for
be performed to assess the iliac fossa for any space-occupying small areas of enhancement that may not be visualized at con-
mass from the adnexa or uterus such as a leiomyoma or prior trast-enhanced CT or contrast-enhanced MRI (Fig 4), the abil-
transplant (Fig 7). Likewise, nephromegaly in patients with ity to perform multiple injections, and real-time assessment
autosomal dominant polycystic kidney disease could interfere of vascularity (24,25). Specific to imaging the kidneys, US
with the site of the intended transplant and necessitate the contrast agents allow improved visualization of the collecting
performance of nephrectomy (19). system and differentiation of the cortex and medulla because

Volume 43 Number 5 6 radiographics.rsna.org

May 2023 Clingan et al

Table 1: Agents for Contrast-enhanced US

Microbubble Approved U.S. Food and

Construct Trade Name Drug Administration Use
Sulfur hexafluo- Lumason (Bracco Cardiac use
ride lipid–type Diagnostics) Characterization of
A microspheres focal hepatic lesions
(adult and pediatric)
Intravesical adminis-
tration
Perflutren lipid Definity (Lantheus Cardiac use
microspheres Medical Imaging)
Perflutren pro- Optison (GE Cardiac use
tein–type A Healthcare)
microspheres
Figure 7. AKCD in a 48-year-old woman undergoing evaluation to assess
the feasibility of retransplant. Coronal noncontrast CT image shows an
atrophic and calcified failed kidney transplant in the left lower quadrant
(arrowhead) and extensive aortoiliac atherosclerotic calcifications (∗), with
relative sparing of the right external artery (arrow). Also note the atrophic Table 2: Hemodialysis Access Sites
native kidneys with small cysts that are consistent with ACKD.
Location AVF AVG
Forearm Radiocephalic Loop graft
they are not renally excreted (25). Limitations of contrast-en- Radiobasilic transposition
hanced US are largely those inherent to US itself. US contrast Upper arm Brachiocephalic Straight graft*
agents are contraindicated for patients who are allergic to the Brachiobasilic transposition Loop graft†
contrast agent or their components, which for sulfur hexaflu- Thigh ... Loop or straight graft†
oride lipid–type A microspheres and perflutren lipid micro-
spheres include polyethylene glycol (28). Note.—AVF = arteriovenous fistula, AVG = arteriovenous graft.
Contrast-enhanced US of indeterminate renal lesions * Brachial artery to basilic or axillary vein.
†
Axillary artery to axillary vein.
tends to be straightforward because the primary question is
whether enhancement is present. Contrast-enhanced US has
been shown to be at least as effective as contrast-enhanced CT
or contrast-enhanced MRI in characterizing kidney lesions
(25,27). Authors of a large study (23) evaluating indetermi- sure the perforator vein, its length, and the distance from the
nate renal masses with contrast-enhanced US demonstrated artery.
high sensitivity and specificity in distinguishing benign from
malignant masses. In our practice, contrast-enhanced US is Imaging for Planning Hemodialysis Access.—In planning for
now preferred by transplant nephrologists for evaluating inci- hemodialysis access procedures, preoperative US mapping of
dentally detected indeterminate renal lesions found with non- the upper extremity or groin vessels can increase successful
contrast CT for kidney transplant evaluation (Fig S3). placement of an AVF in the upper extremity (31,32), help
identify the patient’s risk for immediate failure of the thigh
Imaging for Hemodialysis graft, and improve the overall time before permanent fail-
As patients progress to kidney failure, they ultimately require ure (33). The examination should be performed to evaluate
treatment with either dialysis or a transplant. As of 2019, ap- arterial inflow, venous outflow, and vessel diameter (31–34).
proximately 809 000 people in the United States had kidney Standard protocols with examination steps, details on tech-
failure, with more than 70% undergoing dialysis (1). The main niques to optimize the study, and typical images acquired are
options for permanent hemodialysis access include surgical presented in Table 3 (35). A mapping document can be help-
creation of an arteriovenous fistula (AVF) or placement of a ful for communication among sonographers, radiologists, and
synthetic arteriovenous graft (AVG). Creation of an AVF is vascular surgeons (Fig 9).
preferred because it results in fewer complications such as The Kidney Disease Outcomes Quality Initiative (KDOQI)
infection or thrombosis (29). Hemodialysis access is ideally 2019 guidelines are a reference for the minimum arterial and
placed in the distal forearm of the nondominant arm to assist venous inner lumen diameter (2 mm) necessary for a target
recovery and preserve proximal sites for future use (Table 2, vessel to be considered for an AVF (34). Authors of other stud-
Fig 8). Endovascular devices can now be used to create a per- ies (36) have provided evidence for the use of larger diameter
cutaneous AVF at the antecubital fossa between the proximal cutoff values, because AVF maturity improves with larger ar-
radial or ulnar artery and the adjacent perforating vein, which terial diameters in a linear relationship, without a threshold
drains into the cephalic, basilic, or one of the paired brachial diameter value. Local preferences can guide reference values,
veins (30). This requires additional assessment of the vessels but typical criteria for surgical AVF include a minimum arte-
at the time of the mapping examination to identify and mea- rial diameter of 2.0 mm and a minimum venous diameter of
Volume 43 Number 5 7 radiographics.rsna.org
May 2023 Clingan et al

Figure 8. Illustrations of common access points for hemodialysis in the arm

and groin. Top row left to right shows a radiocephalic arteriovenous fistula
(AVF) in the forearm; a brachiocephalic AVF through the median cubital vein
at the antecubital fossa; a basilic transposition AVF in the upper arm, with the
basilic vein attached to the brachial artery; a loop graft between the cephalic
vein and radial artery in the forearm; a straight graft between the brachial
artery and basilic vein in the upper arm; and a loop graft between the brachial
artery and basilic vein in the upper arm. Bottom row illustration shows a high
loop graft between the common femoral artery and the greater saphenous
vein. a. = artery, v. = vein. (Used with permission of Mayo Foundation for Medi-
cal Education and Research, all rights reserved.)

2.0–2.5 mm. For AVG, the minimum arterial diameter thresh-

old is 2.0 mm, and the minimum venous diameter is 4.0 mm
(34,36–39). For percutaneous AVF, the radial or ulnar artery
near the antecubital fossa should measure at least 2.0 mm, The diameter of the AVF draining vein and the depth from
with a minimum perforating vein diameter of 2.0 mm (30). the skin surface are measured at several locations from the
anastomosis, and the draining vein should be followed to its
Imaging for AVF Maturity.—A mature AVF is ready for hemo- junction with the deep venous system. Areas of narrowing
dialysis when the outflow vein has adequate flow volume and are evaluated for clinically relevant stenosis, as discussed in
the diameter to accommodate cannulation needles. Clinical the next section (43). A draining vein more than 5–6 mm
evaluation at 2 and 4–6 weeks after placement is currently from the skin surface can be challenging to cannulate during
recommended by the KDOQI, with US evaluation for equiv- hemodialysis and typically requires additional surgery to
ocal clinical findings (34). Although the 2006 KDOQI matu- bring the vein closer to the skin surface (40,42). Any acces-
ration “rule of sixes,” with a draining vein diameter of greater sory branches from the draining vein that may shunt flow
than 6 mm, blood flow rate greater than 600 mL/min, and less should be identified, the diameter should be measured, and
than 6 mm of skin depth (40) has been commonly referenced, the location should be documented for possible ablation.
authors of other studies (41) found the combination of a mini- Measurements of flow volume are obtained in the middle
mum 4-mm draining vein and a flow volume greater than 500 draining vein approximately 10 cm cranial to the anastomo-
mL/min had 95% likelihood for AVF maturation. Failed AVF sis in an area with parallel vessel walls, minimal vessel tortu-
maturity may be due to anastomotic or draining vein steno- osity, and no stenosis. This value is calculated with scanner
sis, large accessory veins, or arterial inflow stenosis, and these software using the following equation:
causes can be readily identified with US (42).
Flow (mL/min) = mean velocity (cm/sec) × area
US Evaluation of AVFs and AVGs.—Indications for postoper- (r2π) × 60 sec.
ative US of patients with an AVF or AVG are listed in Table Normal flow volumes are in the range of 500–1500 mL/
4 (43). Spectral color Doppler US should be used to examine min, and low flow from the draining vein can predispose the
the feeding artery upstream from the anastomosis. The AVF patient to thrombosis (43).
anastomosis is evaluated for visible narrowing with B-mode US of AVG is performed similarly to assess for inflow or out-
US, followed by spectral and color Doppler US evaluation. flow abnormalities. Normal AVG material has strong specular

Volume 43 Number 5 8 radiographics.rsna.org

May 2023 Clingan et al

Table 3: Hemodialysis Preoperative Mapping US Protocol

Protocol Step Anatomy Images to Obtain

Arterial Brachial artery at antecubital fossa Longitudinal gray-scale US to assess for calcification or narrowing
evaluation Radial artery at wrist Longitudinal spectral Doppler US peak systolic and end diastolic velocity
Transverse gray-scale US measurement of inner luminal diameter
Documentation of high brachial artery bifurcation, when present
Superficial venous Cephalic vein from shoulder to Transverse gray-scale US to assess for compressibility and thrombus
evaluation wrist Transverse gray-scale US measurement of inner luminal diameter after
Basilic vein from shoulder to an- dilation with a tourniquet
ticubital fossa
Deep venous Internal jugular vein Gray-scale, color, and spectral Doppler US for patency and outflow stenosis
evaluation Subclavian vein or thrombus, with compression, when possible
Additional arterial Radial artery at anticubital fossa Longitudinal gray-scale assessment for calcification or narrowing
evaluation for percu- Ulnar artery at anticubital fossa Longitudinal spectral Doppler US peak systolic and end diastolic velocity
taneous AVF Transverse gray-scale US measurement of inner luminal diameter
Additional venous Perforator vein in continuity with Gray-scale US assessment for compressibility and thrombus
evaluation for percu- cephalic or basilic vein Transverse gray-scale US measurement of inner luminal diameter
taneous AVF Transverse gray-scale US measurement of minimum distance between the
perforator and radial or ulnar artery
Source.—Reference 35.

reflections that appear as thin lines (Fig S4). Doppler US is stenosis and 2:1 for draining vein, central vein, and feeding
used to evaluate the feeding artery, arterial-graft anastomosis, artery stenosis (43). Evaluating the ipsilateral internal jug-
graft (arterial side and venous side if it is a loop graft), venous ular and subclavian veins with spectral Doppler US allows
anastomosis, and draining and central veins. The flow volume assessment for signs of central stenosis (Fig S5).
is assessed in the middle portion of both arterial and venous AVG stenoses are characterized by visual narrowing, an
limbs with loop grafts (43). elevated peak systolic velocity ratio at the venous or arterial
anastomosis, and identification of a high-velocity jet with
Complications of Hemodialysis Access color Doppler US. Although stenosis can occur anywhere
Failure of hemodialysis access can be a result of failure to ma- along the AVG or draining vein, the venous anastomosis is the
ture or secondary failure after a period of successful use. Com- most common location.
plications of access include stenosis, thrombosis, pseudoaneu-
rysm, fluid collections, infection, and the steal phenomenon. Thrombosis
Complete thrombotic occlusion of an AVF or AVG manifests
Stenosis as a lack of a palpable thrill or a failed cannulation at hemo-
AVF stenosis is characterized by (a) visual narrowing greater dialysis. US can allow confirmation of a thrombus and evalu-
than 50% on B-mode US images and (b) an elevated peak sys- ation of its extent to plan a potential intervention for salvage.
tolic velocity ratio when peak systolic velocity is measured at At US, a thrombus is hypoechoic and fills the lumen, with no
or just distal to the narrowed site when compared with the flow at color Doppler US (Fig 11). Draining vein stenosis is
peak systolic velocity 2 cm upstream from the narrowed site the most common cause of AVF thrombosis, with resultant
(Figs 9, 10) (44,45). Using a peak systolic velocity criterion of access failure; other causes include prolonged hypotension or
500 cm/sec for predicting a stenosis of 50% or greater has a hypovolemia, compression after hemodialysis or during sleep,
sensitivity of 89% and a positive predictive value of 99% (46). inflow arterial stenosis, and hypercoagulable states (49).
Stenoses may involve the feeding artery, juxta-anasto-
motic region, draining vein, or central veins. Juxta-anas- Pseudoaneurysm
tomotic stenosis is usually found early after creation of an Pseudoaneurysms can be differentiated from diffuse dilatation
AVF, while draining and central vein stenoses occur later of the hemodialysis access as a focal pulsatile outpouching
(47). Characteristic areas of stenosis relate to the type of that develops because of inadequate compression after can-
access and include the juxta-anastomotic segment in a ra- nulation or repeated access in the same location, occurring
diocephalic AVF, the cephalic arch where the cephalic vein in up to 6% of AVFs and 2%–10% of AVGs (50,51). This false
empties into the axillary vein in a brachiocephalic AVF, and aneurysm is lined only with reactive fibrous tissue, with a
the proximal swing segment of the basilic vein, a surgically high risk for rupture and the potential for catastrophic results
created curve just peripheral to the confluence with the bra- if there is breakdown of the overlying skin (51). Doppler US
chial vein in a brachial artery to a transposed basilic vein shows the characteristic yin-yang flow pattern with to-and-
fistula (48). The ratio criteria for hemodialysis access ste- fro flow in the pseudoaneurysm neck (Fig 12). The distance
nosis differ according to location: 3:1 for juxta-anastomotic from the skin surface to the anterior pseudoaneurysm wall

Volume 43 Number 5 9 radiographics.rsna.org

May 2023 Clingan et al

Figure 9. Radiocephalic AVF of the left arm in a 56-year-old man, with

decreased thrill at hemodialysis. (A) Illustration shows the access anatomy.
Including a mapping document with the examination is useful to illustrate
and communicate findings among sonographers, radiologists, and vascu-
lar surgeons. anast = anastomosis, Dist or dst = distal, hx = history, incr =
increased, Prox = proximal. (B) Longitudinal color and spectral Doppler US
image shows the patency of the AVF, with the expected biphasic low-re-
sistance arterial inflow and a peak systolic velocity of 127 cm/sec. (C) Color
and spectral Doppler US image at the anastomosis shows aliasing, with an
elevated peak systolic velocity of 497 cm/sec (ratio, nearly 4:1). (D) Gray-
scale US image shows narrowing (arrow). (E) Color and spectral Doppler
US image in the radial artery distal to the anastomosis shows reversal of
flow, as can be seen with the steal phenomenon (or syndrome, when it is
associated with symptoms of ischemia).

Volume 43 Number 5 10 radiographics.rsna.org

May 2023 Clingan et al

Table 4: Indications for Postoperative Hemodialysis Access US

Physical Examination Findings Abnormalities at Hemodialysis

Absent or weak palpable thrill Blood flow inadequate for hemodialysis (<500–600 mL/min) or
interval 25% decrease in blood flow
Poor fistula maturation (>6 wk) Difficult cannulation
Persistent ipsilateral edema or pain Access collapse during hemodialysis
Distal limb ischemia Aspiration of thrombus
Clinical signs of infection Elevated venous pressure (>200 mm Hg)
Perigraft mass Elevated recirculation time (>15%)
Follow-up after intervention Low urea reduction rate (<60%)
Prolonged bleeding at access needle site (>20 min)
Source.—Reference 43.

Figure 10. Radiocephalic AVF in the right forearm of a 44-year-old man who

presented with difficult cannulation at hemodialysis. Longitudinal gray-scale
US image (A) and spectral Doppler US images (B, C) show aneurysmal dila-
tation of the cephalic vein greater than 2.0 cm (arrowhead in A) caudal to an
area of associated focal narrowing, collateral vessels, and venous outflow ste-
nosis. The peak systolic velocity of 475 cm/sec represents a 3.3:1 (or greater
than 2:1) ratio from the inflow venous segment peak systolic velocity of 142
cm/sec, 2 cm upstream of the venous stenosis, confirming the diagnosis.

more commonly associated with placement of the AVG, devel-

oping within the 1st month near the arterial anastomosis, and
should contain simple fluid in a well-defined thin margin (49).
Large seromas may require aspiration if there is concern for
compression of the anastomotic region. Lymphoceles develop
from disrupted lymphatic tissue during surgical dissection
and have a similar appearance to that of seromas (51).
Infection occurs predominately in synthetic grafts and is
should be assessed to evaluate the risk for external rupture. more common in those involving the lower extremity, given
An AVG can undergo material degeneration that manifests as its proximity to the groin. Symptoms such as fever, purulent
graft wall irregularity associated with a pseudoaneurysm aris- drainage, and pain and positive blood culture results may help
ing from the defects. to differentiate it from a hematoma, because imaging findings
can overlap (Fig 13) (52).
Fluid Collections
Fluid collections along the hemodialysis access include hema- Arterial Steal
tomas, seromas, and lymphoceles and should be differentiated The arterial steal phenomenon is abnormal reversal of flow in
from pseudoaneurysms and abscesses. Hematomas contain the artery distal to an AVF or AVG. Arterial steal syndrome is
heterogeneous material, depending on the amount of fibrin suspected if blood flow distal to an AVF or AVG anastomosis
and debris, and can extend along the adjacent musculature is reversed away from the hand or foot because of diversion
and subcutaneous plane with ill-defined borders. Seromas are into the hemodialysis access, with associated symptoms such
Volume 43 Number 5 11 radiographics.rsna.org
May 2023 Clingan et al

Figure 11. Brachiobasilic AVF of the left arm in a 48-year-old woman who underwent graft reconstruction and presented with arm swelling
and loss of thrill on examination. (A) Longitudinal spectral Doppler US image in the brachial artery proximal to the AVF shows a triphasic
arterial waveform with high resistance. (B) Longitudinal color Doppler US image of the AVF draining vein shows an echogenic clot and no
flow (arrow), which is compatible with graft occlusion.

Figure 12. Brachiobasilic AVF of the right arm in a 78-year-old woman with a patch to the brachial vein who underwent fistulography 6
weeks previously. (A) Color Doppler US image shows a 3-cm outpouching from the basilic vein with yin-yang color flow (*). (B) Correspond-
ing spectral Doppler US image shows a to-and-fro waveform consistent with a pseudoaneurysm, which was subsequently surgically excised.

as pain and paresthesia worsening during hemodialysis (Fig alysis and offers more independence and mobility because it
9) (53). The steal syndrome in the upper extremity is most can be performed at home. Peritoneal dialysis also offers bet-
common when the brachial artery is used for hemodialysis ter blood pressure control and less cardiovascular stress than
access and in patients with diabetes and older women. US al- does hemodialysis and is preferred for patients with diabetes,
lows confirmation of the reversal of flow in the artery caudal poor vascular access, or cardiac conditions (55). Potential
to the anastomosis that returns to a normal direction toward complications of peritoneal dialysis include infection (bacte-
the hand during brief compression of the AVF. A modified Al- rial or tuberculous peritonitis) and catheter site or “tunnel”
len test before placement of an AVF to document the patency infections (Fig 14). Noninfectious complications include cath-
of the deep palmar arch reduces the likelihood of steal in the eter dysfunction, leakage of dialysate fluid (Fig 15), hernias,
upper extremity. The radial artery is compressed proximal to subcapsular hepatic steatosis, and sclerosing encapsulated
the wrist and imaged at the thenar eminence; if there is rever- peritonitis. The prevalence of sclerosing encapsulated peri-
sal of flow, the palmar arch is patent (43). Arterial steal with tonitis in patients undergoing peritoneal dialysis increases
limb ischemia has also been described (54) as a complication in relation to the duration of treatment (56). Clinical features
of an AVG of the lower extremity in 7%–10% of patients. include a loss of ultrafiltration, abdominal pain, and bloody
dialysis effluent (55). Radiologic features include thickening
Peritoneal Dialysis and calcification of the bowel wall and peritoneum (Figs 16,
More than 62 000 patients in the United States, approximately 17). Early recognition of sclerosing encapsulated peritonitis is
13% of patients undergoing dialysis, undergo peritoneal dial- essential, with immediate cessation of peritoneal dialysis to
ysis (1). Peritoneal dialysis is less costly than traditional di- prevent potentially fatal disease progression (55).

Volume 43 Number 5 12 radiographics.rsna.org

May 2023 Clingan et al

Figure 13. Hemodialysis access infection in two patients. (A, B) Longitudi-

nal gray-scale (A) and color Doppler (B) US images in a 41-year-old woman
with a superficial femoral artery–to–common femoral vein loop graft in the
thigh show irregularity and loss of integrity of the anterior graft wall (arrows).
This graft was surgically removed, and cultures grew Pseudomonas bacte-
ria. (C–E) Brachiocephalic AVF of the left arm in a 58-year-old woman who
underwent placement of a stent in the venous outflow tract and presented
with fever, worsening swelling, and increasing arm pain. Transverse gray-
scale (C) and color Doppler US (D) images show a new pseudoaneurysm (ar-
row) adjacent to the stent (*), with increased volume and complexity of over-
lying fluid (arrowhead) compared with that on the gray-scale US image (E)
acquired 3 days earlier. Blood cultures were positive for Staphylococcus
aureus, and the patient underwent ligation, resection, and patch angioplasty
of the left brachial artery the following day.

Systemic Manifestations of Kidney Failure subtendinous, and subligamentous bone resorption. The
Systemic manifestations in patients with kidney failure are earliest involvement is at the radial aspect of the second and
multifactorial and related to the underlying cause of renal third middle phalanges, which is considered pathognomonic
failure or are secondary to treatment effects. They are influ- (Fig 18) (57). Acroosteolysis of the finger tufts occurs in ad-
enced by biochemical, hormonal, inflammatory, and meta- vanced stages. Additional common subchondral locations
bolic derangements (12). Imaging findings commonly involve include the ilial surface of the sacroiliac joints and along the
the musculoskeletal, neurologic, and cardiothoracic systems. acromioclavicular and sternoclavicular joints (57). Brown
tumors or osteoclastomas are nonaggressive lytic expansile
Musculoskeletal Abnormalities lesions with nonsclerotic margins that represent a reactive
Renal osteodystrophy is bone abnormality resulting from the process related to bone resorption, resulting in hemorrhage,
combination of secondary hyperparathyroidism, osteomala- necrosis ,and cyst formation (57). There can be multiple le-
cia, osteoporosis, and osteosclerosis (57). As kidney function sions, and common locations include the facial bones, ribs,
declines, increased phosphate binds with calcium, leading to and pelvis (Fig 19).
hypocalcemia and increased production of parathyroid hor- Osteomalacia is a consequence of the inability of the fail-
mone to stimulate bone resorption to increase serum calcium ing kidneys to convert vitamin D3 to calcitriol and can result
levels (58,59). Classic imaging findings related to secondary in decreased bone mineralization with coarse ill-defined tra-
hyperparathyroidism include subperiosteal, subchondral, beculae, looser zones or insufficiency fractures, and findings
Volume 43 Number 5 13 radiographics.rsna.org
May 2023 Clingan et al

Figure 14. Tunnel abscess in a 30-year-old woman

undergoing peritoneal dialysis who presented with
pain and drainage at the catheter site. Axial CT image
Figure 16. Sclerosing encapsulated peritonitis in a
obtained with intravenous and oral contrast material
51-year-old woman who underwent a kidney transplant 3
shows free dialysate fluid (∗) and a more focal well-de-
years earlier and presented with chronic abdominal pain.
fined fluid collection with an enhancing rim around the
Before undergoing the transplant, she underwent peri-
peritoneal dialysis catheter (arrow), which is consistent
toneal dialysis for 19 years before transitioning to hemo-
with a tunnel abscess.
dialysis. Radiograph from a small bowel follow-through
examination shows peritoneal calcifications (arrows) and
mild dilatation of the small bowel, with an encapsulated
appearance, which is compatible with sclerosing encap-
sulated peritonitis. Despite this, oral contrast material
reached the distal colon within 2 hours.

Figure 15. Pleuroperitoneal communication in a 60-year-old

man undergoing peritoneal dialysis who developed increasing
shortness of breath and was noted to have a right pleural effu-
sion with glucose at thoracentesis. Peritoneal technetium 99m
(99mTc) scintigram shows a fluid collection in the lower right
hemithorax. 99mTc sulfur colloid was diluted with peritoneal di-
alysis fluid and injected through the peritoneal dialysis cathe- Figure 17. Kidney failure and sclerosing encapsulated peritonitis in
ter, ultimately collecting in the lower right hemithorax, allowing a 67-year-old man who underwent peritoneal dialysis for 1 year. Axial
confirmation of pleuroperitoneal communication. The patient CT image obtained with intravenous and oral contrast material shows
was transitioned to hemodialysis. loculated ascites (*), with peritoneal thickening and enhancement
and cocooning of the small bowel in a sheath of fibrous peritoneum
(arrows). Note the atrophic native kidneys.

related to rickets such as physial irregularity, with cupping

and fraying (57). Osteopenia may represent a combination of Uremic leontiasis ossea is a rare manifestation of renal osteo-
osteoporosis (with decreased bone quality) and osteomalacia dystrophy, with overgrowth of the facial bones including jaw
(with decreased bone mineralization) predisposing patients enlargement, serpiginous tunneling, and cortical resorption
with chronic kidney disease to fracture at a reported twofold (Fig 18) (60). Steroid use after undergoing renal transplant
to 14-fold increased risk (58). can result in osseous changes related to osteonecrosis.
Osteosclerosis commonly involves cancellous bone of the In addition to bone changes, patients with kidney failure are
axial skeleton (57). Involvement along the endplates of the predisposed to extraskeletal manifestations for which KDIGO
vertebral bodies is known as a rugger jersey spine (Fig 19). has proposed the broader term, chronic kidney disease mineral
Volume 43 Number 5 14 radiographics.rsna.org
May 2023 Clingan et al

Figure 18. Extensive skeletal changes

related to renal osteodystrophy in a 31-year-
old man with kidney failure requiring dialysis
since he was 16 years old. (A) Anteropos-
terior radiograph of the left hand shows
marked diffuse osteopenia, with extensive acroosteolysis of all digits and subperiosteal resorption pri-
marily along the radial aspect of the middle phalanges (arrow) due to secondary hyperparathyroidism.
Also note prominent vascular calcification in the distal radial soft tissues (arrowhead). (B) Three-dimen-
sional reconstruction maxillofacial CT image shows findings of uremic leontiasis ossea, with increased
interdental spacing (arrow). (C) Axial maxillofacial CT image shows the marked expansion and heteroge-
neous attenuation of the maxilla and mandible, with sclerosis and serpiginous trabeculations (arrows).

Figure 19. Renal osteodystrophy in a

40-year-old woman with kidney failure.
(A) Axial contrast-enhanced CT image
through the thorax shows an expansile
lesion (arrow) involving the left seventh
rib that is consistent with a brown tumor.
(B) Sagittal lumbar spine CT image shows
diffuse osteosclerosis of the spine, with a
loss in vertebral body height and endplate
sclerosis, resulting in a “rugger jersey”
appearance. The spine and rib findings are
consistent with renal osteodystrophy.

bone disorder, to reflect disturbances in mineral and bone me- articular locations, is often bilateral and symmetric, and
tabolism as well as soft-tissue and vascular calcifications (59). commonly deposits around the hips and shoulders (Fig 20).
Soft-tissue calcification is more common in patients undergo- Metastatic pulmonary calcifications may be seen in the chest
ing dialysis who have a calcium-phosphorus product greater (Fig 21). Vascular calcification of medium-sized arteries and
than 70 mg2/dL2 (61). Uremic tumoral calcinosis favors peri- visceral calcification also occurs and increases cardiovascular
Volume 43 Number 5 15 radiographics.rsna.org
May 2023 Clingan et al

Figure 20. Uremic tumoral calcinosis in a 48-year-old man undergo- Figure 21. Metastatic pulmonary calcifications in a 51-year-old man with
ing hemodialysis after a failed kidney transplant. Coronal noncontrast kidney failure who was undergoing hemodialysis and had an abnormal
CT image of the chest shows a large cloudlike collection of periartic- chest radiograph (not shown). Axial noncontrast CT image of the chest
ular calcifications involving the right shoulder, with similar findings in shows centrilobular high attenuation and ground-glass nodules forming
the left subclavian space (arrows). Note additional calcifications as- small rosettes in the upper lobes, representing calcium deposition in nor-
sociated with known stenosis of the superior vena cava (arrowhead) mal lung parenchyma. Chronic kidney failure and hypercalcemia are pre-
and a vascular stent in the left neck (∗). disposing factors for pulmonary calcifications.

Figure 22. Kidney failure in a 43-year-old woman who was undergoing hemodialysis and
presented with a painful mass and swelling in the right thigh, ultimately developing ulcer-
ation and a chronic wound requiring débridement. (A) 99mTc bone scintigram shows soft-tis-
sue uptake along the right posterolateral thigh greater than that on the left (arrow), which is
consistent with calciphylaxis, or calcific uremic arteriolopathy affecting small arteries and re-
sulting in ischemia leading to skin infarctions and necrosis. (B) Axial noncontrast CT image
acquired before scintigraphy was performed shows small-vessel calcifications (arrow), skin
thickening (arrowhead), and inflammation of the subcutaneous fat in this location, which
were noticed only during a retrospective review of this image.

risk (57). Calciphylaxis or calcific uremic arteriolopathy is an-

other finding seen in patients with kidney failure, resulting in
ischemia and necrosis in the skin and subcutaneous fat (Fig
22) (62). Patients with chronic kidney disease are also predis-
posed to crystal deposition disease and amyloid deposition
related to dialysis, which can result in a spondyloarthropathy
(Fig 23) (57). β2 microglobulin deposition is more likely with
prolonged dialysis and has a predisposition for osteoarticular
structures, but it can involve any organ and often manifests
with calcification (57).

Neurologic Complications
Neurologic complications are common in patients with kid-
ney failure and may be related to vascular damage from hy-
pertension, uremia, fluctuations in water content and blood
pressure, systemic anticoagulant therapy, infection, and ane-
mia (12,63). Moderate to severe cognitive impairment is re-
ported to be 2.5 times higher in patients undergoing dialysis
(63). Kidney failure is associated with cerebral atrophy and
a loss of gray-matter volume (64). Cerebral ischemia and in-
farction may occur secondarily to arterial damage and emboli,
and chronic white-matter changes related to microvascular
ischemia are nearly twice as common in patients undergoing
dialysis than they are in the general population (65). Uremia
and systemic anticoagulation place patients undergoing he-
modialysis at a greater risk of bleeding, with a five- to 10-times
higher incidence of intracerebral hemorrhage and a higher

Volume 43 Number 5 16 radiographics.rsna.org

May 2023 Clingan et al

Figure 23. Amyloid deposition in two patients. (A) Sagittal noncon-

trast CT image of the lumbar spine in a 53-year-old man with kidney
failure secondary to diabetic nephropathy who had been undergoing
hemodialysis for 7 years shows destructive discovertebral changes
including endplate erosions (arrow) and a compression fracture at T11
(arrowhead), probably secondary to amyloid and crystal deposition
(dialysis related or uremic spondyloarthropathy). Differential diagnos-
tic considerations include discitis-osteomyelitis and gout; however,
the lack of surrounding reactive sclerosis is atypical for discitis, and
the lack of calcification in the endplate erosion argues against gout
tophus. (B) Coronal CT image in a 75-year-old man shows retroperito-
neal soft-tissue thickening and calcification (arrows), which is indica-
tive of amyloidosis.

edema, with expansile increased T2 signal intensity involving

the basal ganglia surrounded by a T2-hyperintense rim de-
fining the lentiform nucleus (70,71). Cerebral edema may be
seen with azotemia and dialysis disequilibrium syndrome, in
which patients present with neurologic symptoms after he-
modialysis from an osmotic gradient developing between the
brain and plasma (72).

Cardiothoracic Complications
More than 50% of patients with kidney failure who are treated
with hemodialysis die of cardiovascular disease (12,73).
Complications are associated with accelerated atherosclero-
sis, hyperlipidemia, hypertension, myocardial dysfunction,
and pericarditis, and calcifications of the coronary arter-
ies, valves, and myocardium are common (12). In addition
to myocardial infarction, cardiovascular death also results
from heart failure and arrhythmias. Growing evidence sug-
gests that structural changes occur in patients with uremic
cardiomyopathy related to microvascular ischemia, anemia,
chronic inflammation, and pressure or volume overload, re-

ventricular mass index (74,75). β2 microglobulin amyloid

sulting in myocardial edema, fibrosis, and an increased left
Figure 24. Cerebral amyloid angiopathy in a 72-year-
old woman. Axial susceptibility-weighted MR image
shows multifocal punctate foci of low signal intensity
deposits have also been found in the heart in patients un-
or black dots (arrowhead) bilaterally, likely related to dergoing long-term hemodialysis (12). Imaging findings in
microhemorrhage. these patients include those of congestive heart failure (Fig
27). Interstitial and alveolar edema and pleural effusions are
the most common thoracic manifestations in patients with
incidence of microhemorrhage (Fig 24) (66,67). Changes in kidney failure, especially with volume overload between
water content and accumulation of metabolites may cause dialysis sessions. Infection is also possible, because immu-
edema and demyelination, leading to osmotic demyelination nosuppression predisposes those with kidney failure to a
syndrome (Fig 25) (65,69). Sudden changes in blood pressure, higher frequency of pulmonary infections. Staphylococcus
which are common in patients undergoing hemodialysis, can aureus is the most common cause of bacterial infection in
result in posterior reversible encephalopathy (Fig 26) (68). patients undergoing long-term hemodialysis, and these pa-
The lenticular fork sign has been described with metabolic ac- tients are also at risk for active tuberculosis after primary
idosis, diabetes, and uremic encephalopathy and results from infection or reactivation of quiescent disease (12).

Volume 43 Number 5 17 radiographics.rsna.org

May 2023 Clingan et al

Figure 25. Osmotic demyelination syndrome

in a 56-year-old woman with kidney failure and
a history of two unsuccessful kidney transplants
who was undergoing hemodialysis. (A) Axial T2-
weighted fluid-attenuated inversion-recovery MR
image of the brain at the level of the lateral ventri-
cles shows multifocal white matter hyperintensities
(arrowheads) corresponding to chronic small
vessel ischemia. (B) Axial T2-weighted fluid-atten-
uated inversion-recovery MR image at the level of
the brainstem shows heterogeneous hyperinten-
sities throughout the pons (arrow), representing
edema and myelinolysis typical of osmotic demye-
lination syndrome.

Figure 27. Cardiomegaly and interstitial edema in an

80-year-old woman with dyspnea who missed one of her
scheduled appointments for dialysis. Portable frontal radio-
Figure 26. Vasogenic edema and encephalopathy graph of the chest shows cardiomegaly with interstitial edema
in a 72-year-old woman with kidney failure who was and Kerley B lines (arrow).
undergoing hemodialysis. Axial T2-weighted fluid-
attenuation inversion-recovery MR image shows
subcortical hyperintensities in both occipital lobes Author affiliations.—From the Departments of Radiology (M.J.C., Z.Z.,
(arrow), greater on the right, reflecting areas of va- M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500
sogenic edema, which can be seen with posterior San Pablo Rd, Jacksonville FL 32224. Presented as an education exhibit at
reversible encephalopathy syndrome associated with the 2021 RSNA Annual Meeting. Received May 8, 2022; revision requested
hypertension and uremic encephalopathy. June 17 and received July 15; accepted July 19. Address correspondence to
M.J.C. (email: Clingan.mary@mayo.edu).

Disclosures of conflicts of interest.—D.A.B. Speaker for MRI Online. All

Conclusion other authors, the editor, and the reviewers have disclosed no relevant
Imaging has an important role in diagnosis, screening, treat- relationships.
ment planning, and monitoring in patients with kidney
References
disease. Kidney failure is a complex systemic process and
1. United States Renal Data System. USRDS Annual Data Report: Epide-
involves more than just the kidneys. Patients with kidney fail- miology of kidney disease in the United States. Bethesda, Md: National
ure require special consideration with respect to how they are Institutes of Health, National Institute of Diabetes and Digestive and
imaged, although screening recommendations and adminis- Kidney Diseases, 2021.
2. Stevens PE, Levin A; Kidney Disease: Improving Global Outcomes Chronic
tration of iodinated contrast media and GBCM have evolved. Kidney Disease Guideline Development Work Group Members. Evaluation

Volume 43 Number 5 18 radiographics.rsna.org

May 2023 Clingan et al

and management of chronic kidney disease: synopsis of the kidney disease: 27. Cantisani V, Bertolotto M, Clevert DA, et al. EFSUMB 2020 Proposal for
improving global outcomes 2012 clinical practice guideline. Ann Intern a Contrast-Enhanced Ultrasound-Adapted Bosniak Cyst Categorization -
Med 2013;158(11):825–830. Position Statement. Ultraschall Med 2021;42(2):154–166.
3. Levin A, Stevens PE, Bilous RW, et al. Kidney Disease: Improving Global 28. American College of Radiology. FDA Warns Against Some Ultrasound
Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice Contrast Agents in Patients with PEG Allergy. https://www.acr.org/Advoca-
guideline for the evaluation and management of chronic kidney disease. cy-and-Economics/Advocacy-News/Advocacy-News-Issues/In-the-April-
Kidney Int Suppl 2013;3(1):1–150. 24-2021-Issue/FDA-Warns-Against-Some-Ultrasound-Contrast-Agents.
4. Kellum JA, Lameire N, Aspelin P, et al. Kidney disease: improving global Published April 22, 2021. Accessed February 22, 2022.
outcomes (KDIGO) acute kidney injury work group. KDIGO clinical prac- 29. Vascular Access 2006 Work Group. Clinical practice guidelines for vascular
tice guideline for acute kidney injury. Kidney Int Suppl 2012;2(1):1–138. access. Am J Kidney Dis 2006;48(Suppl 1):S176–S247.
5. Davenport MS, Perazella MA, Yee J, et al. Use of Intravenous Iodinated 30. Wasse H, Alvarez AC, Brouwer-Maier D, et al. Patient selection, education,
Contrast Media in Patients with Kidney Disease: Consensus Statements and cannulation of percutaneous arteriovenous fistulae: An ASDIN White
from the American College of Radiology and the National Kidney Foun- Paper. J Vasc Access 2020;21(6):810-817.
dation. Radiology 2020;294(3):660–668. 31. Robbin ML, Gallichio MH, Deierhoi MH, Young CJ, Weber TM, Allon M.
6. ACR Committee on Drugs and Contrast Media. ACR Manual on Contrast US vascular mapping before hemodialysis access placement. Radiology
Media. https://www.acr.org/Clinical-Resources/Contrast-Manual. Pub- 2000;217(1):83–88.
lished 2021. Accessed May 6, 2022. 32. Allon M, Lockhart ME, Lilly RZ, et al. Effect of preoperative sonographic
7. Inker LA, Eneanya ND, Coresh J, et al. New Creatinine- and Cysta- mapping on vascular access outcomes in hemodialysis patients. Kidney
tin C-Based Equations to Estimate GFR without Race. N Engl J Med Int 2001;60(5):2013–2020.
2021;385(19):1737–1749. 33. Little MD, Allon M, McNamara MM, et al. Risk Evaluation of Immediate
8. Oloko A, Talreja H, Davis A, et al. Does Iodinated Contrast Affect Residual Surgical Failure During Thigh Hemodialysis Graft Placement by Sono-
Renal Function in Dialysis Patients? A Systematic Review and Meta-Anal- graphic Screening. J Ultrasound Med 2015;34(9):1613–1619.
ysis. Nephron 2020;144(4):176–184. 34. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for
9. Macdonald DB, Hurrell CD, Costa AF, et al. Canadian Association of Vascular Access: 2019 Update. Am J Kidney Dis 2020;75(4 Suppl 2):S1–
Radiologists Guidance on Contrast-Associated Acute Kidney Injury. Can S164 [Published correction appears in Am J Kidney Dis 2021;77(4):551.].
J Kidney Health Dis 2022;9:20543581221097455. 35. The AIUM Practice Parameter for the Performance of Ultrasound
10. Weinreb JC, Rodby RA, Yee J, et al. Use of Intravenous Gadolinium-based Vessel Mapping Prior to Dialysis Access Creation. J Ultrasound Med
Contrast Media in Patients with Kidney Disease: Consensus Statements from 2022;41(4):E16–E20.
the American College of Radiology and the National Kidney Foundation. 36. Farrington CA, Robbin ML, Lee T, Barker-Finkel J, Allon M. Early Pre-
Radiology 2021;298(1):28–35. dictors of Arteriovenous Fistula Maturation: A Novel Perspective on an
11. Woolen SA, Shankar PR, Gagnier JJ, MacEachern MP, Singer L, Daven- Enduring Problem. J Am Soc Nephrol 2020;31(7):1617–1627.
port MS. Risk of Nephrogenic Systemic Fibrosis in Patients With Stage 37. Sidawy AN, Spergel LM, Besarab A, et al. The Society for Vascular
4 or 5 Chronic Kidney Disease Receiving a Group II Gadolinium-Based Surgery: clinical practice guidelines for the surgical placement and
Contrast Agent: A Systematic Review and Meta-analysis. JAMA Intern maintenance of arteriovenous hemodialysis access. J Vasc Surg 2008;48(5
Med 2020;180(2):223–230. Suppl):2S–25S.
12. Degrassi F, Quaia E, Martingano P, Cavallaro M, Cova MA. Imaging 38. Glass C, Johansson M, DiGragio W, Illig KA. A meta-analysis of preop-
of haemodialysis: renal and extrarenal findings. Insights Imaging erative duplex ultrasound vessel diameters for successful radiocephalic
2015;6(3):309–321. fistula placement. J Vasc Ultrasound 2009;33(2):65–68.
13. Tsuzuki T, Iwata H, Murase Y, Takahara T, Ohashi A. Renal tumors in end- 39. Misskey J, Hamidizadeh R, Faulds J, Chen J, Gagnon J, Hsiang Y. Influence
stage renal disease: A comprehensive review. Int J Urol 2018;25(9):780–786. of artery and vein diameters on autogenous arteriovenous access patency.
14. Berkenblit R, Ricci Z, Kanmaniraja D, Sarungbam J. CT features of ac- J Vasc Surg 2020;71(1):158–172.e1.
quired cystic kidney disease-associated renal cell carcinoma. Clin Imaging 40. Vascular Access 2006 Work Group. Clinical practice guidelines for vascular
2022;83:83–86. access. Am J Kidney Dis 2006;48(Suppl 1):S176–S247.
15. Silverman SG, Pedrosa I, Ellis JH, et al. Bosniak Classification of Cystic 41. Robbin ML, Chamberlain NE, Lockhart ME, et al. Hemodialysis arte-
Renal Masses, Version 2019: An Update Proposal and Needs Assessment. riovenous fistula maturity: US evaluation. Radiology 2002;225(1):59–64.
Radiology 2019;292(2):475–488. 42. Singh P, Robbin ML, Lockhart ME, Allon M. Clinically immature ar-
16. El-Zaatari ZM, Truong LD. Renal Cell Carcinoma in End-Stage Renal teriovenous hemodialysis fistulas: effect of US on salvage. Radiology
Disease: A Review and Update. Biomedicines 2022;10(3):657. 2008;246(1):299–305.
17. Tordjman M, Dbjay J, Chamouni A, et al. Clear Cell Papillary Renal Cell 43. AIUM Practice Parameter for the Performance of Vascular Ultrasound
Carcinoma: A Recent Entity With Distinct Imaging Patterns. AJR Am J Examinations for Postoperative Assessment of Hemodialysis Access. J
Roentgenol 2020;214(3):579–587. Ultrasound Med 2020;39(5):E39–E48.
18. Shrewsberry AB, Osunkoya AO, Jiang K, et al. Renal cell carcinoma in 44. Clark TW, Hirsch DA, Jindal KJ, Veugelers PJ, LeBlanc J. Outcome and
patients with end-stage renal disease has favorable overall prognosis. Clin prognostic factors of restenosis after percutaneous treatment of native
Transplant 2014;28(2):211–216. hemodialysis fistulas. J Vasc Interv Radiol 2002;13(1):51–59.
19. Catalá V, Martí T, Diaz JM, et al. Use of multidetector CT in presurgical 45. Beathard GA, Arnold P, Jackson J, Litchfield T; Physician Operators Forum
evaluation of potential kidney transplant recipients. RadioGraphics of RMS Lifeline. Aggressive treatment of early fistula failure. Kidney Int
2010;30(2):517–531. 2003;64(4):1487–1494.
20. Hernández D, Vázquez T, Armas-Padrón AM, et al. Peripheral Vascular 46. Wo K, Morrison BJ, Harada RN. Developing Duplex Ultrasound Criteria for
Disease and Kidney Transplant Outcomes: Rethinking an Important On- Diagnosis of Arteriovenous Fistula Stenosis. Ann Vasc Surg 2017;38:99–104.
going Complication. Transplantation 2021;105(6):1188–1202. 47. Mehta HJ. Central Venous Stenosis: What Should a Nephrologist Know?
21. Werlin EC, Braun HJ, Walker JP, et al. Utility of a Simplified Iliac Artery Indian J Nephrol 2017;27(6):427–429.
Calcium Scoring System to Guide Perioperative Management for Renal 48. Quencer KB, Arici M. Arteriovenous Fistulas and Their Characteristic Sites
Transplantation. Front Med (Lausanne) 2021;8:606835. of Stenosis. AJR Am J Roentgenol 2015;205(4):726–734.
22. Harmath CB, Wood CG 3rd, Berggruen SM, Tantisattamo E. Renal Pre- 49. Meola M, Marciello A, Di Salle G, Petrucci I. Ultrasound evaluation of access
transplantation Work-up, Donor, Recipient, Surgical Techniques. Radiol complications: Thrombosis, aneurysms, pseudoaneurysms and infections.
Clin North Am 2016;54(2):217–234. J Vasc Access 2021;22(1_suppl):71-83.
23. Barr RG, Peterson C, Hindi A. Evaluation of indeterminate renal masses 50. Huber TS, Carter JW, Carter RL, Seeger JM. Patency of autogenous and
with contrast-enhanced US: a diagnostic performance study. Radiology polytetrafluoroethylene upper extremity arteriovenous hemodialysis ac-
2014;271(1):133–142. cesses: a systematic review. J Vasc Surg 2003;38(5):1005–1011.
24. Kazmierski B, Deurdulian C, Tchelepi H, Grant EG. Applications 51. Padberg FT Jr, Calligaro KD, Sidawy AN. Complications of arteriovenous
of contrast-enhanced ultrasound in the kidney. Abdom Radiol (NY) hemodialysis access: recognition and management. J Vasc Surg 2008;48(5
2018;43(4):880–898. Suppl):55S–80S.
25. Barr RG, Wilson SR, Lyshchik A, et al. Contrast-enhanced Ultrasound-State 52. Finlay DE, Longley DG, Foshager MC, Letourneau JG. Duplex and color
of the Art in North America: Society of Radiologists in Ultrasound White Doppler sonography of hemodialysis arteriovenous fistulas and grafts.
Paper. Ultrasound Q 2020;36(4S Suppl 1):S1–S39. RadioGraphics 1993;13(5):983–989.
26. Kazmierski BJ, Sharbidre KG, Robbin ML, Grant EG. Contrast-Enhanced 53. Leake AE, Winger DG, Leers SA, Gupta N, Dillavou ED. Management
Ultrasound for the Evaluation of Renal Transplants. J Ultrasound Med and outcomes of dialysis access-associated steal syndrome. J Vasc Surg
2020;39(12):2457–2468. 2015;61(3):754–760.
Volume 43 Number 5 19 radiographics.rsna.org
May 2023 Clingan et al

54. Antoniou GA, Lazarides MK, Georgiadis GS, Sfyroeras GS, Nikolopoulos 66. Yokoyama S, Hirano H, Uomizu K, Kajiya Y, Tajitsu K, Kusumoto K. High
ES, Giannoukas AD. Lower-extremity arteriovenous access for haemodi- incidence of microbleeds in hemodialysis patients detected by T2*-weighted
alysis: a systematic review. Eur J Vasc Endovasc Surg 2009;38(3):365–372. gradient-echo magnetic resonance imaging. Neurol Med Chir (Tokyo)
55. Stuart S, Booth TC, Cash CJ, et al. Complications of continuous ambulatory 2005;45(11):556–560; discussion 560.
peritoneal dialysis. RadioGraphics 2009;29(2):441–460. 67. Watanabe A. Cerebral microbleeds and intracerebral hemorrhages
56. Rigby RJ, Hawley CM. Sclerosing peritonitis: the experience in Australia. in patients on maintenance hemodialysis. J Stroke Cerebrovasc Dis
Nephrol Dial Transplant 1998;13(1):154–159. 2007;16(1):30–33.
57. Murphey MD, Sartoris DJ, Quale JL, Pathria MN, Martin NL. Muscu- 68. Fugate JE, Rabinstein AA. Posterior reversible encephalopathy syndrome:
loskeletal manifestations of chronic renal insufficiency. RadioGraphics clinical and radiological manifestations, pathophysiology, and outstanding
1993;13(2):357–379. questions. Lancet Neurol 2015;14(9):914–925.
58. Babayev R, Nickolas TL. Bone Disorders in Chronic Kidney Disease: An 69. Tarhan NC, Agildere AM, Benli US, Ozdemir FN, Aytekin C, Can U.
Update in Diagnosis and Management. Semin Dial 2015;28(6):645–653. Osmotic demyelination syndrome in end-stage renal disease after recent
59. Ketteler M, Block GA, Evenepoel P, et al. Executive summary of the hemodialysis: MRI of the brain. AJR Am J Roentgenol 2004;182(3):809–816.
2017 KDIGO Chronic Kidney Disease-Mineral and Bone Disorder 70. Kumar G, Goyal MK. Lentiform Fork sign: a unique MRI picture. Is met-
(CKD-MBD) Guideline Update: what’s changed and why it matters. abolic acidosis responsible? Clin Neurol Neurosurg 2010;112(9):805–812.
Kidney Int 2017;92(1):26–36 [Published correction appears in Kidney Int 71. Kim DM, Lee IH, Song CJ. Uremic Encephalopathy: MR Imaging Findings
2017;92(6):1558.]. and Clinical Correlation. AJNR Am J Neuroradiol 2016;37(9):1604–1609.
60. Alamer A. Uremic leontiasis ossea: distinctive imaging features allow 72. Chen CL, Lai PH, Chou KJ, Lee PT, Chung HM, Fang HC. A prelimi-
differentiation from other clinical causes of leontiasis ossea. Radiol Case nary report of brain edema in patients with uremia at first hemodialysis:
Rep 2021;17(3):553–557. evaluation by diffusion-weighted MR imaging. AJNR Am J Neuroradiol
61. Cofan F, García S, Combalia A, Campistol JM, Oppenheimer F, Ramón 2007;28(1):68–71.
R. Uremic tumoral calcinosis in patients receiving longterm hemodialysis 73. Aoki J, Ikari Y. Cardiovascular Disease in Patients with End-Stage Renal
therapy. J Rheumatol 1999;26(2):379–385. Disease on Hemodialysis. Ann Vasc Dis 2017;10(4):327–337.
62. Yerram P, Chaudhary K. Calcific uremic arteriolopathy in end stage renal 74. Kott J, Reichek N, Butler J, Arbeit L, Mallipattu SK. Cardiac Imaging in
disease: pathophysiology and management. Ochsner J 2014;14(3):380–385. Dialysis Patients. Kidney Med 2020;2(5):629–638.
63. Chen HJ, Zhang LJ, Lu GM. Multimodality MRI Findings in Patients with 75. Garikapati K, Goh D, Khanna S, Echampati K. Uraemic Cardiomy-
End-Stage Renal Disease. BioMed Res Int 2015;2015:697402. opathy: A Review of Current Literature. Clin Med Insights Cardiol
64. Zhang LJ, Wen J, Ni L, et al. Predominant gray matter volume loss in 2021;15:1179546821998347.
patients with end-stage renal disease: a voxel-based morphometry study.
Metab Brain Dis 2013;28(4):647–654.
65. Ağildere AM, Kurt A, Yildirim T, Benli S, Altinörs N. MRI of neurologic
complications in end-stage renal failure patients on hemodialysis: pictorial
review. Eur Radiol 2001;11(6):1063–1069.

TM
This journal-based CME activity has been approved for AMA PRA Category 1 Credit . See rsna.org/learning-center-rg.

Volume 43 Number 5 20 radiographics.rsna.org