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
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May 2023 Clingan et al
Supplemental RadioGraphics 2023; 43(5):e220116
https://doi.org/10.1148/rg.220116
Material
Content Codes: CT, GU, MR, US
Quiz questions for this Abbreviations: ACKD = acquired cystic kid-
article are available ney disease, ACR = American College of Ra-
in the supplemental diology, AVF = arteriovenous fistula, AVG =
material. arteriovenous graft, eGFR = estimated
glomerular filtration rate, GBCM = gadolin-
ium-based contrast media, KDIGO = Kid-
ney Disease Improving Global Outcomes,
KDOQI = Kidney Disease Outcomes Quality
Initiative, NKF = National Kidney Foundation,
RCC = renal cell carcinoma
TEACHING POINTS
„ Patients with acute kidney injury or stage 4 or 5 chronic kidney disease who
are not undergoing dialysis have a relative (but not absolute) contraindica-
tion for iodinated contrast media, and when it is required for diagnosis of
life-threatening conditions, its use should not be withheld.
„ 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
patients with acute kidney injury or an eGFR of less than 30 mL/min per 1.73
m2 is likely to outweigh the risk of its use for indicated examinations.
„ Two distinct RCC subtypes occurring more frequently or exclusively in pa-
tients with kidney failure have been described in studies during the past de-
cade: ACKD-associated RCC and clear cell papillary RCC.
„ The ratio criteria for hemodialysis access stenosis differ according to location:
3:1 for juxta-anastomotic stenosis and 2:1 for draining vein, central vein, and
feeding artery stenosis.
„ In addition to bone changes, patients with kidney failure are predisposed
to extraskeletal manifestations for which KDIGO has proposed the broader
term, chronic kidney disease mineral bone disorder, to reflect disturbances
in mineral and bone metabolism as well as soft-tissue and vascular calcifi-
cations.
Introduction
Chronic kidney disease affects approximately 15% of adults
in the United States or nearly 37 million people (1). The Kid-
ney Disease Improving Global Outcomes (KDIGO) practice
guidelines define chronic kidney disease as abnormalities in
kidney structure or function that are present for greater than 3
months, with health implications, which can be classified on
the basis of cause, albuminuria category, or estimated glomer-
ular filtration rate (eGFR). Radiologists are most interested in
the imaging implications for patients with stage 4 (eGFR <
30 mL/min per 1.73 m2) and stage 5 (eGFR < 15 mL/min per
1.73 m2) chronic kidney disease, with stage 5 considered kid-
ney failure (2,3). KDIGO defines acute kidney injury as an in-
crease in a patient’s serum creatinine level of greater than or
equal to 0.3 mg/dL within 48 hours or of greater than or equal
to 1.5 times the baseline known or presumed level within the
prior 7 days, or a urine volume of less than 0.5 mL per kilo-
gram per hour for 6 hours (4).
Renal function may influence both why and how a patient
may be imaged. The radiologist should be aware of imaging
findings that are specific to patients with kidney failure. This
article serves as a broad review of imaging in patients with
kidney failure, starting with new guidelines for contrast ma-
terial and recommendations for screening and prophylaxis.
Renal manifestations of kidney failure, pretransplant imag-
Volume 43 Number 5 2 radiographics.rsna.org
ing, and contrast-enhanced US for problem solving are dis-
cussed, with an emphasis on renal tumors and vasculature.
We cover imaging for hemodialysis access, maturation crite-
ria, and assessment of complications, including those of peri-
toneal dialysis. Because kidney failure affects more than just
the kidneys, commonly encountered systemic manifestations
involving the musculoskeletal, neurologic, and cardiothoracic
systems are also reviewed.
Contrast Media Guidelines, Screening, and
Prophylaxis
Iodinated Contrast Media
The risk of acute kidney injury from the use of iodinated con-
trast material at CT has been overstated because of a historic
lack of control groups to separate contrast material–induced
(ie, contrast-induced) acute kidney injury from contrast-asso-
ciated acute kidney injury, which is a correlative diagnosis (5–
7). The most important risk factor for contrast-induced acute
kidney injury is preexisting severe renal insufficiency, and the
calculated eGFR is more accurate than the serum creatinine
level and is a better marker of the risk of contrast-induced
acute kidney injury (5,6). New eGFR equations that are not
based on the patient’s race but instead incorporate creatinine
and cystatin C levels are more accurate and lead to smaller
differences in eGFR between races (7). Currently there is little
evidence that intravenous iodinated contrast media is an in-
dependent risk factor for acute kidney injury in patients with
an eGFR greater than 30 mL/min per 1.73 m2 (5).
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
screening and prophylaxis and important considerations from
a consensus statement from the American College of Radiol-
ogy (ACR) and the National Kidney Foundation (NKF) for the
use of intravenous iodinated contrast media in patients with
kidney disease are summarized in Figure 1 (5). Patients with
acute kidney injury or stage 4 or 5 chronic kidney disease who
are not undergoing dialysis have a relative (but not absolute)
contraindication for iodinated contrast media, and when it is
required for diagnosis of life-threatening conditions, its use
should not be withheld. Volume expansion with normal sa-
line solution is indicated as prophylaxis for contrast-induced
acute kidney injury in patients with an eGFR of less than 30
mL/min per 1.73 m2 who are not undergoing maintenance
dialysis if there are no contraindications (5). There is no in-
dication to initiate or change dialysis on the basis of the ad-
ministration of iodinated contrast media, regardless of renal
function. Standard contrast material dosing is recommended,
because a reduced dose may result in suboptimal images (5,6).
If a patient is undergoing dialysis and is experiencing anu-
ria, iodinated contrast media may be used without concern.
A patient who is undergoing dialysis and making urine has
a theoretical risk for further loss of residual renal function.
The ACR and NKF recommend treating these patients as
they would treat those with acute kidney injury or an eGFR
of less than 30 mL/min per 1.73 m2 who are not undergoing
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
meta-analysis (8) found that iodinated contrast media may
not result in a significant reduction of residual function in
patients undergoing dialysis, prompting the Canadian Asso-
ciation of Radiologists to conclude that the presence of urine
output in patients undergoing dialysis should not influence
the use of iodinated contrast media (9).
Gadolinium-based Contrast Media
Gadolinium-based contrast media (GBCM) are categorized
into three groups (Fig 2) on the basis of risk of or association
with nephrogenic systemic fibrosis. Nephrogenic systemic
fibrosis is a systemic disease characterized by fibrosis of the
skin and other tissues that is triggered by exposure to GBCM
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).
Nearly all unconfounded cases of nephrogenic systemic fi-
brosis were linked to Group I agents, which are now contra-
indicated for use in patients at risk for nephrogenic systemic
fibrosis (6,10). 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 patients
with acute kidney injury or an eGFR of less than 30 mL/
min per 1.73 m2 is likely to outweigh the risk of its use for
indicated examinations (10). Authors of a 2020 systematic
review and meta-analysis (11) showed 0 events after 4931
administrations of group II GBCM to patients with an eGFR
of less than 30 mL/min per 1.73 m2. Assessment of kidney
Volume 43 Number 5 3 radiographics.rsna.org
function is now optional before administration of a group
II agent (6). Few if any unconfounded cases of nephrogenic
systemic fibrosis have been reported with Group III agents,
but data are limited and kidney function screening remains
necessary (6). Recommendations for screening, and import-
ant considerations from consensus statements from the ACR
and the NKF for the use of GBCM in patients with kidney
disease are summarized in Figure 2 (10).
No prophylaxis reduces the risk of nephrogenic systemic fi-
brosis. For patients undergoing dialysis, group II GBCM must
be used and attempts can be made to coordinate the MRI ex-
amination before regularly scheduled postexamination dial-
ysis. Otherwise, dialysis should not be initiated or altered on
the basis of administration of group II or III GBCM (10).
Primary Manifestations of Kidney Failure
Acquired Cystic Kidney Disease
The longer patients are undergoing dialysis, the more likely
they are to develop acquired cystic kidney disease (ACKD),
which is reported in 10%–20% of patients after 1–3 years and
more than 90% of patients after 5–10 years of dialysis (12).
Imaging findings include normally sized or atrophic kidneys
with multiple small cysts of varying complexity, regardless of
the initial cause of renal failure or the method of dialysis. The
incidence of renal cell carcinoma (RCC) is threefold to 24-fold
higher in patients with kidney failure than it is in the general
population (13), and patients with ACKD have more than a
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
evaluation to distinguish among simple cysts, cystic renal
masses, and solid masses. Noncontrast CT is frequently per-
formed in patients with renal disease, and any heterogeneous
lesion or a focal kidney lesion measuring more than 20 HU or
less than 70 HU is indeterminate and warrants further evalu-
ation (15). Contrast-enhanced US is an alternative to GBCM
or iodinated contrast media in this patient population (Fig 3).
Kidney Tumors
All major RCC subtypes have been reported in patients with
kidney failure to include a higher percentage of papillary RCC
and chromophobe RCC (16). Two distinct RCC subtypes oc-
curring more frequently or exclusively in patients with kidney
failure have been described (13,16) in studies during the past
decade: ACKD-associated RCC and clear cell papillary RCC.
ACKD-RCC is specific to patients with kidney failure and may
occur in a cyst in a background of multiple cysts. ACKD-RCC
can be multifocal or bilateral and is usually low grade with
indolent biologic behavior, although sarcomatoid and rhab-
doid features have been described (16). ACKD-RCC has tu-
mor cells with abundant eosinophilic or a clear cytoplasm and
prominent nucleoli with a sievelike appearance secondary to
cytoplasmic or intracellular vacuolation and characteristic in-
tratumoral calcium oxalate crystals (Fig S1) (16). CT features
of ACKD-RCC have been described as rounded, well-defined,
and often exophytic lesions that are commonly isoattenuating
on noncontrast CT images and can be solid, cystic, or mixed
in attenuation on contrast-enhanced CT images (Fig 4) (14).
Clear cell papillary RCC has been reported in patients with
kidney failure or ACKD, but it also can occur sporadically
Volume 43 Number 5 4 radiographics.rsna.org
and is the fourth most common RCC subtype after clear cell
RCC, papillary RCC, and chromophobe RCC (13). Clear cell
papillary RCC is characterized by cuboidal to columnar clear
cells, with a tubulopapillary arrangement and horizontally
aligned nuclei, with inverse polarity, and shows at least fo-
cal papillary architecture (Fig S2) (16). Two imaging patterns
have been described with clear cell papillary RCC: (a) solid
heterogeneous tumors with minor cystic changes and rare
calcification, which show T2 hyperintensity, arterial enhance-
ment, and delayed washout similar to the appearance of clear
cell RCC (Fig 5) or (b) cystic clear cell papillary RCC with a
predominantly unilocular pattern often classified as Bosniak
III or IV (17) (Fig 6). Clear cell papillary RCC demonstrates
indolent behavior, with no recurrences or metastatic disease
reported to date (13).
Anastomosing hemangiomas of the kidney are rare be-
nign vascular tumors that are seen mostly in patients with
kidney failure. They are small (<2 cm) and composed of si-
nusoidal capillary-sized vessels lined by flat or hobnail en-
dothelial cells (13). An anastomosing hemangioma of the
kidney occurs in the medulla, often abuts the kidney sinus
fat, and demonstrates arterial enhancement indistinguish-
able from RCC (13).
Although long-term (>20 years) hemodialysis has been as-
sociated as an unfavorable prognostic factor for RCC because
of the potential for sarcomatoid transformation, patients with
RCC and kidney failure have a favorable overall prognosis
(13,18) likely because of the indolent histopathologic charac-
teristics of kidney failure–associated RCC and the likelihood of
early diagnosis. The risk of recurrent RCC in patients with kid-
ney failure is lower than that in the general population, which
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
while awaiting transplant (18).
Imaging in Patients with Kidney Failure
Pretransplant Imaging
Imaging may be requested for a potential kidney transplant re-
cipient before surgery. Typically, noncontrast CT is performed
to assess the technical feasibility of a transplant, evaluate for
peripheral vascular disease, and detect coexisting conditions
that would change patient treatment, such as renal stones,
infection, or an underlying malignancy (19). Pretransplant
imaging is more likely to be ordered for patients older than
50 years, those with diabetes or hypertension as the cause of
chronic kidney disease, and those with known atherosclerosis
such as ischemic heart disease or peripheral vascular disease
(19).
Evaluation of the external iliac arteries and their inflow
for peripheral vascular disease guides surgical planning, be-
cause detection of peripheral vascular disease in patients with
kidney failure is associated with worse patient and allograft
survival (20). Heterotopic transplants usually involve the ex-
ternal iliac arteries, and surgeons need an arterial segment of
at least 3 cm, without calcifications (19). Peripheral vascular

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

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

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

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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).

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Table 4: Indications for Postoperative Hemodialysis Access US

Physical Examination Findings Abnormalities at Hemodialysis

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

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-

should be assessed to evaluate the risk for external rupture.
An AVG can undergo material degeneration that manifests as
graft wall irregularity associated with a pseudoaneurysm aris-
ing from the defects.
Fluid Collections
Fluid collections along the hemodialysis access include hema-
tomas, seromas, and lymphoceles and should be differentiated
from pseudoaneurysms and abscesses. Hematomas contain
heterogeneous material, depending on the amount of fibrin
and debris, and can extend along the adjacent musculature
and subcutaneous plane with ill-defined borders. Seromas are
Volume 43 Number 5 11 radiographics.rsna.org
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
more common in those involving the lower extremity, given
its proximity to the groin. Symptoms such as fever, purulent
drainage, and pain and positive blood culture results may help
to differentiate it from a hematoma, because imaging findings
can overlap (Fig 13) (52).
Arterial Steal
The arterial steal phenomenon is abnormal reversal of flow in
the artery distal to an AVF or AVG. Arterial steal syndrome is
suspected if blood flow distal to an AVF or AVG anastomosis
is reversed away from the hand or foot because of diversion
into the hemodialysis access, with associated symptoms such
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
9) (53). The steal syndrome in the upper extremity is most
common when the brachial artery is used for hemodialysis
access and in patients with diabetes and older women. US al-
lows confirmation of the reversal of flow in the artery caudal
to the anastomosis that returns to a normal direction toward
the hand during brief compression of the AVF. A modified Al-
len test before placement of an AVF to document the patency
of the deep palmar arch reduces the likelihood of steal in the
upper extremity. The radial artery is compressed proximal to
the wrist and imaged at the thenar eminence; if there is rever-
sal of flow, the palmar arch is patent (43). Arterial steal with
limb ischemia has also been described (54) as a complication
of an AVG of the lower extremity in 7%–10% of patients.
Peritoneal Dialysis
More than 62 000 patients in the United States, approximately
13% of patients undergoing dialysis, undergo peritoneal dial-
ysis (1). Peritoneal dialysis is less costly than traditional di-
alysis and offers more independence and mobility because it
can be performed at home. Peritoneal dialysis also offers bet-
ter blood pressure control and less cardiovascular stress than
does hemodialysis and is preferred for patients with diabetes,
poor vascular access, or cardiac conditions (55). Potential
complications of peritoneal dialysis include infection (bacte-
rial or tuberculous peritonitis) and catheter site or “tunnel”
infections (Fig 14). Noninfectious complications include cath-
eter dysfunction, leakage of dialysate fluid (Fig 15), hernias,
subcapsular hepatic steatosis, and sclerosing encapsulated
peritonitis. The prevalence of sclerosing encapsulated peri-
tonitis in patients undergoing peritoneal dialysis increases
in relation to the duration of treatment (56). Clinical features
include a loss of ultrafiltration, abdominal pain, and bloody
dialysis effluent (55). Radiologic features include thickening
and calcification of the bowel wall and peritoneum (Figs 16,
17). Early recognition of sclerosing encapsulated peritonitis is
essential, with immediate cessation of peritoneal dialysis to
prevent potentially fatal disease progression (55).

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

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

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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

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

Volume 43 Number 5 17 radiographics.rsna.org

May 2023 Clingan et al
Figure 26. Vasogenic edema and encephalopathy
in a 72-year-old woman with kidney failure who was
undergoing hemodialysis. Axial T2-weighted fluid-
attenuation inversion-recovery MR image shows
subcortical hyperintensities in both occipital lobes
(arrow), greater on the right, reflecting areas of va-
sogenic edema, which can be seen with posterior
reversible encephalopathy syndrome associated with
hypertension and uremic encephalopathy.
Conclusion
Imaging has an important role in diagnosis, screening, treat-
ment planning, and monitoring in patients with kidney
disease. Kidney failure is a complex systemic process and
involves more than just the kidneys. Patients with kidney fail-
ure require special consideration with respect to how they are
imaged, although screening recommendations and adminis-
tration of iodinated contrast media and GBCM have evolved.
Volume 43 Number 5 18 radiographics.rsna.org
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-
graph of the chest shows cardiomegaly with interstitial edema
and Kerley B lines (arrow).
Author affiliations.—From the Departments of Radiology (M.J.C., Z.Z.,
M.P.C., K.L.C., V.G., D.A.B., L.F.A.) and Pathology (Q.J.Z.), Mayo Clinic, 4500
San Pablo Rd, Jacksonville FL 32224. Presented as an education exhibit at
the 2021 RSNA Annual Meeting. Received May 8, 2022; revision requested
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
other authors, the editor, and the reviewers have disclosed no relevant
relationships.
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