Ultrasound as a tool for the differential diagnosis of renal

failure
Poster No.:

C-1350

Congress:

ECR 2010

Type:

Scientific Exhibit

Topic:

Genitourinary

Authors:

C. Akgul Ozmen, D. Akin, S. Uysal Bilek, A. Hasanefendioglu

Bayrak, S. Senturk, H. Nazaroglu; Diyarbakir/TR

Keywords:

acute renal failure, chronic renal failure, ultrasound

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Page 1 of 14

Purpose
Renal ultrasound (US) is the most appropriate method of imaging for both acute and
chronic renal failure [1]. It provides information on the status of the renal parenchyma.
A small kidney with a thin, highly echogenic parenchyma without hydronephrosis is
characteristic of chronic renal failure and helps to avoid unnecessary work up and
interventions [2,3]. In contrast, normal-sized kidneys with normal or only moderately
abnormal echogenicity may indicate less severe disease. However, there is considerable
overlap in renal size and renal echogenicity between normally and abnormally functioning
kidneys, and the morphologic appearance of kidneys does not therefore always match
the renal diagnosis or the renal function. Defining atrophic kidneys or small kidney on
ultrasound is a matter of debate. Kidney size may vary with body size or height, sex or
presence of diabetes [2, 4-6]. Diabetic kidney is the major cause of chronic renal failure
(CRF) and often looks "better" than the kidney with same degree of chronic changes
caused by other renal disease [2,3]. Cortical thinning is a common finding of CRF and
more pronounced in hypertensive nephrosclerosis [2,3].
Distinguishing acute from chronic renal failure is often possible using pre-morbid serum
creatinine concentration. Although good medical registry systems in developed countries
have decreased the magnitude of the problem, patients with CRF often do not admit to
hospitals until their renal failure becomes advanced and uremic symptoms arise, and
then they present 'acutely' for the first time in advanced renal failure requiring emergent
dialysis.
Some clinical and laboratory parameters can help decide whether renal failure is acute
or chronic [7-9]. Unfortunately, in a considerable number of cases, a decision cannot
be made based on laboratory parameters because some tests have a low sensitivity,
whereas others have low specificity. Furthermore, some of these methods are not widely
available, and some are costly.
Although renal US is recommended as the most appropriate method for imaging both
acute and chronic renal failure, and many studies have investigated the sonographic
features of acute or chronic renal failure, we did not encounter any cohort studies in which
the diagnostic role of US was compared in patients with acute renal failure (ARF) and
CRF [1]. We aimed to compare sonographic features of kidneys in patients with ARF
and CRF and to investigate the potential role of renal US to distinguish ARF from CRF
in new patients referred to our renal unit. We also aimed to assess the diagnostic role
of body surface area (BSA)-corrected renal length compared with measured renal length
in this context.

Page 2 of 14

Methods and Materials

This prospective study included 127 (66 female, 61 male) consecutive patients referred
to our renal unit between May 2007 and December 2008 with a serum creatinine greater
than 3 mg/dl and who were admitted for the first time. Patients were divided into two
groups by the nephrologists, those with ARF (n = 62) and those with CRF (n = 65),
based on relevant past medical history and previous serum creatinine measurements,
radiological and clinical evidence of renal osteodystrophy, and on the eventual diagnosis
and prognosis. Patients on renal replacement treatment (hemodialysis, peritoneal
dialysis, or renal transplantation) and those with prerenal azotemia and a prompt
response to volume replacement were not included. Patients with solitary kidney and liver
disease were excluded from the analysis. A group of health workers with no known renal
disease (18 females and 15 males) and serum creatinine levels in the normal range were
included as the control group.
Conventional gray-scale renal US scanning was performed using a Toshiba SSH-140A
US machine equipped with a 3.75-MHz convex probe. Renal length was measured along
the longest axis of the kidney. Renal parenchymal echogenicity was graded on a fourlevel scale using the normal liver or spleen as a reference: Grade 0: The echogenicity of
the cortex of the right kidney was less than that of the liver. Grade I: The echogenicity
of the cortex of the right kidney equaled that of the liver. Grade II: The echogenicity of
the cortex of the right kidney was greater than that of the liver but less than that of the
renal sinus. Grade III: The echogenicity of the renal cortex was equal to that of the renal
sinus, as described previously [10].
Distinctness of the corticomedullary (CM) junction and the presence of stones and cysts
were recorded. Parenchymal thickness was defined as the distance between the sinus
fat and the renal capsule; it was measured in three different areas (superior, middle, and
lower), and an average value was calculated. The sonographic data were recorded on a
data form by radiologists who were blinded to the final ARF or CRF diagnosis.
Patient characteristics and serum levels of urea, creatinine, hemoglobin, and albumin
were analyzed. Height, weight, and the measured BSA were recorded for each subject
2

0.425

according to the Dubois formula: Body surface area (m ) = 0.007184 weight (kg)
0.725

height (cm)
. The causes of renal failure in the ARF group were categorized
as ischemic acute tubular necrosis (ATN) in 30 patients (20.4%) (prolonged prerenal
azotemia, sepsis, postoperative renal failure), toxic ATN in 19 patients (12.9%) (drug,
radiocontrast agent), and others in 13 patients (8.8%) (postpartum, vasculitis, multiple
etiologies). The underlying renal disease in patients with CRF were diabetes mellitus in
19 patients (28.4%), hypertension in 20 (29.8%), obstructive nephropathy in four (6.0%),

Page 3 of 14

chronic glomerulonephritis in seven (10.4%), other etiology in two (3.0%), and unknown
etiology in 13 patients (19.4%).
The results are expressed as means standard deviations. Comparisons between the
ARF and CRF groups were performed using the Student's t-test for parametric values and
the chi-square test for frequencies. A one-way analysis of variance was used to compare
the means of the control group with the ARF and CRF groups. A post hoc Dunnett's test
was used to analyze the difference between the acute and chronic renal failure groups
and the control group. A p-value <0.05 was considered statistically significant. Receiver
operating characteristic (ROC) curve analysis was performed to investigate the role of
sonographic parameters for distinguishing ARF from CRF. Sonographic lengths were
2

adjusted to 1.73 m and compared with the measured values to distinguish ARF from
CRF. All patients gave informed consent to participate in this study.

Results
The patients in the control group had a mean age of 49 13 years, weight of 69 9
2

kilograms, height of 166 6 cm, and BSA of 1.76 0.11 m . No significant difference for
age, weight, height, BSA, or gender distribution was found between patients with ARF
or CRF and the control group. Serum urea and creatinine were significantly higher in
patients with ARF and CRF compared to control group (p < 0.0001 for both), and serum
hemoglobin level was lower in those with ARF (p = 0.035) and CRF (p < 0.0001) than
in controls. No significant differences for age, serum albumin, urea, creatinine, weight,
height, BSA, or gender distribution were observed between patients with ARF and CRF
(Table 1). However, serum hemoglobin level was significantly higher (p < 0.0001) in
patients with ARF than in those with CRF. The parenchymal thickness and renal length of
both the right and left kidney were significantly higher in patients with ARF than in those
with CRF (p < 0.0001) (Table 2). We found no difference between right and left kidney
length and parenchymal thickness in the ARF and CRF groups (data not shown). The
mean renal length and parenchymal thickness of the control group were 107 6 mm and
13.6 1.4 mm, respectively. These were similar to the ARF group (p > 0.05 for both) and
significantly higher than the CRF group (p < 0.0001 for both)
Table 1: Characteristics and laboratory results of patients with ARF and CRF

Female/Male
(n)

ARF (n=62)

CRF (n=65)

Control (n=33)

34/28

32/33

18/15

ns

Page 4 of 14

Age (years)

5322

5320

49 13

ns

Urea 8934

9140

306

ns

Serum
6.84.4
creatinine (mg/
dl)

8.04.2

1.00.2

ns

Hemoglobin (g/ 11.22.5

dl)

9.32.2

12.31.6

<0.0001

Height (cm)

1629

1648

166 6

ns

Weight (kg)

6512

6713

69 9

ns

1.730.18

1.76 0.11

ns

Serum
(mg/dl)

Body

surface 1.690.18
2

Area (m )
: the p value is obtained from comparison of subjects with ARF and CRF

Table 2 Sonographic results of patients with ARF and CRF

ARF (n=62)

CRF (n=65)

Control (n=33)

Right
renal 11214
length (mm)

9015

106 7

<0.0001

Left
renal 11214
length (mm)

9116

108 7

<0.0001

Right
13.83.5
parenchymal
thickness (mm)

10.94.5

13.7 1.4

<0.0001

Left
parenchymal
thickness

10.64.6

13.6 1.5

<0.0001

Mean
renal 11214
length (mm)

9015

107 6

<0.0001

Mean
13.83.4
parenchymal
thickness (mm)

10.74.2

13.6 1.4

<0.0001

BSA-corrected 11616
mean
renal
length (mm)

9115

106 10

<0.0001

13.73.5

Page 5 of 14

BSA-corrected 14.23.1
mean
parenchymal
thickness (mm)
Right Cortical
19
echogenity

10.84.1

13.4 1.6

27

<0.0001

<0.0001

Grade 0

33

32

Grade I

10

27

Grade II

28

Grade III
Left
Cortical
23
echogenity

<0.0001

Grade 0

35

36

Grade I

21

Grade II

Left
CM 90.3
distinction (%)

60.0

84.8

<0.0001

Right
CM 87.1
distinction (%)

63.1

87.9

0.002

Cyst (%)

14.5

30.8

15.1

0.029

Stone (%)

21.0

20.0

18.8

ns

Ectasia (%)

16.1

12.3

ns

Grade III

the p value is obtained from comparison of subjects with ARF and CRF.

Cortical echogenicity was higher in patients with CRF than in those with ARF (Table
2). Normal echogenicity was present in only four right and three left kidneys. A very
hyperechogenic renal cortex was only present in patients with CRF and in no case of ARF.
Grade I hyperechogenicity was the most common finding during sonography in patients
with ARF and CRF (Table 2). Distinctness of the corticomedullary junction was achieved
at a higher rate in patients with ARF than those with CRF (Table 2). The presence of a
simple renal cyst was more common in the CRF than the ARF group (30.8% vs. 14.5%).
The rates of stone detection or minimal ecstasies were similar in both groups (p > 0.05).

Page 6 of 14

The sonographic features of the subjects with ischemic acute tubular necrosis (ATN),
toxic ATN, and ATN due to other causes are shown in Table 3.
Table 3. Sonographic results of patients with ARF
Ischemic ATN Toxic
(n=30)
(n=19)

ATN Others (n=13)

Mean
renal 11112
length (mm)

11210

11619

ns

BSA-corrected 11511
mean
renal
length (mm)

11717

11622

ns

Mean
13.02.7
parenchymal
thickness (mm)

14.43.5

14.84.1

ns

BSA-corrected 13.63.0
mean
parenchymal
thickness (mm)

14.6 2.3

14.84.4

ns

5 (26.3%)

2 (15.4%)

0.243

14 (73.7%)

11 (84.6%)

4 (21.1%)

4 (30.8%)

15 (78.9%)

9 (69.2%)

Left
CM 86.7
distinction (%)

100

84.6

0.087

Right
CM 80
distinction (%)

100

84.6

0.044

Right Cortical
12 (40%)
echogenity
Grade 0

18 (60%)

Grade I-II
Left
Cortical
15(50%)
echogenity
Grade 0

15(50%)

0.108

Grade I-II

A comparison of the sonographic features of patients with various CRF etiologies

revealed that diabetic subjects were different from the remaining CRF patients. The
measured and BSA-corrected mean renal length and parenchymal thickness were
significantly higher in diabetic than in nondiabetic CRF patients. Distinctness of the CM

Page 7 of 14

junction was achieved at a higher rate in patients with diabetic CRF than those with
nondiabetic CRF (Table 4).
Table 4. Sonographic results of patients with CRF
DM

Non-DM

HT

CGN

Urologic

Others
(n=15)

P*

(n=19)

(n=46)

(n=20)

(n=7)

(n=4)

Mean
renal
length
(mm)

10412

8512

8311

9013

8210

8512

<0.0001

c-Mean
renal
length
(mm)

10212

8714

8412

9317

9019

8514

<0.0001

Mean
14.23.5 9.33.6
parenchyma
thickness
(mm)

10.33.9 11.84.6 7.00.7

7.50.7

<0.0001

c-Mean 13.93.2 9.53.7

parenchyma
thickness
(mm)

10.43.9 12.14.7 7.71.5

7.51.9

<0.0001

Right
1
Cortical
echogenity13

19

12

Grade 0

18

Grade I

20

11

Grade II
Grade III
Left
1
Cortical
echogenity16
Grade 0

20

Grade I

Page 8 of 14

Grade II
Grade III
Left CM 78.9
distinction
(%)

52.2

70

57.1

25

33.3

0.045

Right
89.5
CM
distinction
(%)

52.2

70

57.1

25

33.3

0.005

Cyst (%)

31.6

30.4

35

42.8

25

20

ns

Stone
(%)

21.1

19.6

15

28.6

25

20

ns

Ectasia
(%)

15.8

10.9

10

14.3

25

6.7

ns

*: the p value is obtained from comparison of subjects with diabetic and non diabetic CRF.
While performing the sonographic parameter ROC analysis to discriminate ARF from
CRF, we found that the area under the curve was higher for length than for parenchymal
thickness and was slightly higher for BSA-corrected length and parenchymal thickness
than for their measured counterparts (Figure 1). The cut-offs for 100% sensitivity and
100% specificity were 71 mm and 127 mm mean measured length, and they were 75 mm
and 121 mm for the BSA-corrected mean length, respectively.

Figure 1: ROC Area under curve for differential diagnosis of renal failure

Page 9 of 14

Fig.
References: C. Akgul Ozmen; Department of Radiology, Dicle University School of
Medicine Department of Radiology, Diyarbakir, TURKEY
Figure 1: (A) ROC analysis curve for the optimal cut-off point of mean parenchymal
thickness (line) and BSA-corrected mean parenchymal thickness (dashed line) for
discriminating between ARF group and CRF group. AUC, areas under the curve are 0.714
and 0.724, respectively. (B) ROC analysis curve for the optimal cut-off point of mean
renal length (line) and BSA-corrected mean renal length (dashed line) for discriminating
between ARF group and CRF group. AUC, areas under the curve are 0.865 and 0.873,
respectively.

Conclusion

Page 10 of 14

Mean renal length averages 11 cm in healthy adults [5], and 10 to 12 cm is a useful range
for normal renal length at average body height. Mean renal length for patients with ARF
(112 14 mm) was similar to that in healthy adults derived from data of the literature
(11 cm) and the volunteers in our study (107 6 mm). Not surprisingly, it was shorter in
patients with CRF (90 15 mm) than in healthy adults. Hellstrm et al. [6] reported that
the mean renal length measured by sonography was approximately 88 mm in patients
with CRF, which was similar to our results. A mean renal length of 100-105 mm has been
reported in patients with ARF [11].
Cortical echogenicity was higher in patients with CRF than in those with ARF in our study.
Normal echogenicity was present in only four right and three left kidneys. Grade III renal
cortex echogenicity was only present in patients with CRF and in no case of ARF. Slight
hyperechogenicity (grade I) was the most common finding during sonography of patients
with ARF and CRF; therefore, the echogenicity has less value in distinguishing ARF from
CRF. In a study of 153 adult patients undergoing sonography for nonrenal indications, the
renal cortex and liver had the same echogenicity in 60 patients, 43 of whom had normal
renal function [12]. Therefore, cortical echogenicity is a poor parameter for evaluating
kidneys. Only very hyperechogenic kidneys (grade III) may be a sign of CRF. Hellstrm
et al. [6] reported that the kidneys of chronic glomerulonephritis (CGN) patients were
significantly more echogenic than those of diabetic CRF patients (p = 0.001). The median
echogenicity of the CGN patients in that study was grade II compared with grade I in
the diabetic CRF group. The prevalence of grade II-III hyperechoic kidneys was lower
in patients with diabetic CRF than those with CRF due to nondiabetic etiologies in our
study (Table 4)
Although no normal range has been established for parenchymal thickness, a value of
15 to 16 mm was obtained in a large adult cohort [5], and a parenchymal thickness of 14
mm has been reported in patients with ARF [6]. We found that the mean parenchymal
thickness in patients with ARF (13.8 3.4 mm) was similar to a previous report and to
the healthy controls in our study (13.6 1.4 mm) but significantly higher than patients
with CRF (10.7 4.2 mm) (p < 0.0001). Therefore, parenchymal thickness also seems
to be an important parameter to distinguish acute from chronic renal failure.
The sonographic appearance of ATN is quite variable and can be normal in many cases
[10,13-16]. Toxic ATN alone accounts for the increase in echogenicity, suggesting that
increased echogenicity is limited to this form [15]. Some other studies have also reported
that increased echogenicity is more frequently noted with toxic ATN [17,18], whereas a
normal or enlarged hypoechoic cortex is seen in ischemic ATN [15,17]. Two reasons may
explain normal sonographic appearance in ATN. First, ATN may not alter the sonographic
appearance in some cases. Second, changes in size or echogenicity may occur that
cannot be diagnosed in the absence of baseline examinations or are not severe enough to
render the kidneys abnormal. These factors may limit the diagnostic utility of sonography
for acute renal failure. Parenchymal thickness and renal length were similar in our study.

Page 11 of 14

Distinctness of the CM junction was achieved at a higher rate in patients with ARF than
those with CRF (Table 3), and this may also be useful for distinguishing ARF from CRF.
The presence of a simple renal cyst was more common in patients with CRF than in those
with ARF (30.8% vs. 14.5%). Hellstrm et al. [6] reported that renal cysts were found
during US in 43/67 (64%) of patients with CRF. CGN was the most common CRF etiology
in their population, with 70% cyst prevalence, but their study included an approximately
10-year older study population, which may account for the differences in the results.
Another study reported renal cysts in 50% of patients with analgesic nephropathy, 31%
of patients with pyelonephritis, and only 14% and 11% of patients with glomerulonephritis
and diabetic glomerulosclerosis, respectively [19]. The prevalence of a simple renal cyst
in the present study was in the range of these two studies [6,19].
Diabetic subjects were different from nondiabetic CRF patients. The measured and BSAcorrected mean renal length and parenchymal thickness were significantly higher in
diabetic than in nondiabetic CRF patients. Nishimura et al. [20] found that diabetic CRF
2

patients (3979 608 mm /1.48 m ) had a renal area index (BSA-corrected renal length
2

renal width) slightly lower than healthy subjects (4396 580 mm /1.48 m ) but higher than
2

nondiabetic CRF patients (3272 856 mm /1.48 m ). The mean renal length measured
by sonography was significantly larger in DN patients (100.3 15.7 mm) than in CGN
patients (79.7 8.4 mm) (p = 0.0003) in a previous report [6], which was similar to our
results. In our study, mean renal length was 104 12 mm in patients with diabetic CRF
and 85 12 mm in nondiabetic patients with CRF. The mean parenchymal thickness
in patients with diabetic CRF (14.2 3.5 mm) was also higher than in nondiabetic
patients with CRF (9.3 3.6 mm). Diabetic patients are most challenging in the context
of distinguishing ARF from CRF because they have sonographic features intermediate
between acute and chronic renal failure. Therefore, the presence of diabetes mellitus
should be known before making a decision regarding kidney sonographic findings.
The areas under the ROC curve for BSA-corrected mean renal length and BSA-corrected
mean parenchymal thickness were 0.873 and 0.724. This result supports the use of
US to distinguish acute from chronic renal failure. However, the differences between
measured and BSA-corrected renal length and mean parenchymal thickness were 0.008
and 0.010, only slightly favoring the use of corrected values. This difference may have
no or little clinical significance. BSA-corrected values may only be necessary for subjects
in extreme weight or height percentiles. No single sonographic parameter has a high
enough sensitivity and specificity to distinguish acute from chronic renal failure.
The distinction between ARF and CRF is a challenge, especially when no recent
serum creatinine measurements are available. Many clinical, laboratory, and radiological
parameters have been used with the aim of making this distinction [7-9]. Unfortunately,
in a considerable number of cases, these parameters cannot be used because some
have low sensitivity, whereas others have low specificity. Additionally, these methods are
not widely available and are costly. The major limitations of the study were the operator

Page 12 of 14

dependence of the method, lack of histological diagnosis, and the low number of subjects
in the CRF subgroups with urologic disorders or CGN.
Renal length, parenchymal thickness, and echogenicity differed significantly between
patients with acute and those with chronic renal failure. Diabetic subjects with CRF
had different sonographic features than did patients with other etiologies. BSA-corrected
values may only be necessary for subjects in extreme weight or height percentiles. A
renal US examination is still the most appropriate and commonly used method for imaging
acute and chronic renal failure, and it should be combined with other tests to distinguish
acute from chronic renal failure.

References
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Personal Information

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