Appropriate Use Criteria
ACR Appropriateness Criteria® Renal Failure

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Abstract

Renal failure can be divided into acute kidney injury and chronic kidney disease. Both are common and result in increased patient morbidity and mortality. The etiology is multifactorial and differentiation of acute kidney injury from chronic kidney disease includes clinical evaluation, laboratory tests, and imaging. The main role of imaging is to detect treatable causes of renal failure such as ureteral obstruction or renovascular disease and to evaluate renal size and morphology. Ultrasound is the modality of choice for initial imaging, with duplex Doppler reserved for suspected renal artery stenosis or thrombosis. CT and MRI may be appropriate, particularly for urinary tract obstruction. However, the use of iodinated and gadolinium-based contrast should be evaluated critically depending on specific patient factors and cost-benefit ratio.

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Section snippets

Introduction/Background

Renal failure is defined as the inability of the kidney to secrete nitrogenous wastes and maintain fluid and electrolyte homeostasis, leading to azotemia. Acute kidney injury (AKI) is the preferred term for an abrupt decline in function. Chronic kidney disease (CKD) is abnormal renal function present for >3 months. AKI is defined as an increase in creatinine by ≥0.3 mg/dL within 48 hours or an increase in serum creatinine to ≥1.5 times baseline (within prior 7 days) or urine volume ≤0.5

Arteriography Kidney

Arteriography is reserved for intervention rather than for the initial diagnosis of AKI. Renal revascularization may be considered in a very select group of patients with AKI. There is no relevant literature regarding the use of arteriography in the evaluation of AKI.

CT Abdomen and Pelvis

Unenhanced CT abdomen and pelvis is useful for further evaluation of US-detected hydronephrosis by determining level and cause of obstruction. CT is the most sensitive modality for urinary tract calculi and more sensitive than US

Summary of Recommendations

  • Variant 1: US kidneys retroperitoneal is usually appropriate for the initial imaging of unspecified AKI. US is used to detect hydronephrosis and evaluate renal size and morphology.

  • Variant 2: US kidneys retroperitoneal is usually appropriate for the initial imaging of CKD. Small and/or scarred kidneys confirm the diagnosis.

  • Variant 3: US kidneys retroperitoneal is usually appropriate for the initial imaging of renal failure of unknown duration. US is used to detect hydronephrosis and evaluate

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an

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  • The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.

    Reprint requests to: [email protected].

    Dr Lockhart reports Deputy Editor salary from Journal of Ultrasound in Medicine, other support from Elsevier, Oxford Publishers, Jaypee Brothers Medical Publishers, outside the submitted work. Dr Lyshchik reports research support: GE Healthcare, Bracco Diagnostics, Siemens Healthineers, Canon Medical Systems; Advisory Board: Bracco Diagnostics; Consulting: GE Healthcare, Bioclinica, World Care Clinical; Speaker Panel: GE Healthcare; Book Royalties: Elsevier. Dr Smith reports personal fees from GE, Canon Medical, Algomedica, grants from GE, outside the submitted work; In addition, Dr. Smith has a patent issued to AI Metrics LLC. Dr Wong-You-Cheong reports personal fees from Elsevier outside the submitted work. The other authors state that they have no conflict of interest related to the material discussed in this article. All the authors are non-partner/non-partnership track employees.

    Disclaimer: The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

    The ACR Appropriateness Criteria documents are updated regularly. Please go to the ACR website at www.acr.org/ac to confirm that you are accessing the most current content.

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