Renal Transplant Protocol

• Start intravenous line (20 or 22 gauge iv). If iv calibre is small (i.e. 22 gauge) then pre-warm the gadolinium contrast to body temperature to reduce its viscosity.
• Oxygen, 2-4 liters/min by nasal canulae is helpful if patient is short of breath
• Valium (5-10mg po) or Xanax (1-2 mg po) if patient is claustrophobic

Coil: Body coil is best because of its large field-of-view that allows imaging from diaphragm to femoral heads. If using the torso array, consider rotating 90 degrees for greater S/I coverage.

Patient Positioning: Supine, feet first,

Landmark: Iliac crest or transplant scar.

(A)	(B)	(C)	(D)

First determine the location of the transplanted kidney. Most often the donor kidney is transplanted into the pelvis and anastomosed to the external iliac artery and vein (A). It may also be in the pelvis with an end-to-end arterial anastomosis to the internal iliac artery (B). Rarely, if the donor kidneys are small (i.e. from a baby) both kidneys are transplanted together en bloc (C). When the transplant kidney si in the pelvis a landmark a little below the iliac crest. Occasionally a donor kidney is transplanted into the site of a native kidney (D). Usually this happens when pelvic surgery is not feasible. In this instance landmark a little above the iliac crest.

Series 1: Coronal SSFSE

This sequence is useful to assess the region around the allograft for fluid collections, renal allograft parenchyma and urinary tract for obstruction. It also provides anatomical information about allograft location, size and morphology.

Series 2: Sagital T1

This sequence is used to prescribe the coronal 3D volume & tracker positioning. It also assesses cortico-medullary differentiation and help characterize perinephric fluid collections.

This sequence is complementary to series 1 (coronal SSFSE) in assessing and characterizing fluid collections and pelvis masses.

Series 4: Coronal 3D Gd MRA

This is the main sequence to evaluate the allograft vasculature for stenosis or occlusion and to roughly assess allograft perfusion by observing the degree of renal enhancement. It evaluates function by looking at gadolinium excretion into the urinary tract.
The 3D volume is centered on the allograft. It should encompass the lower abdominal aorta and extends sufficiently anteriorly to include the femoral heads, it is necessary to include the internal and external iliac in the imaging volume to ensure that the anastomosis is included. Use Smart-prep ensure synchronization of central k-space with arrival of the bolus to acquire the center of k-space data during the arterial enhancement before venous enhancement.

Series 5: Axial 3D phase contrast

This sequence is prescribed from the collapse image of the 3D Gd-MRA. The 3D volume is positioned to cover the iliac and allograft vessels. Performing this sequence after the 3D Gd-MRA will increase the signal to noise radio by taking advantage of the previously injected gadolinium contrast. This sequence is useful to assess the severity of any stenosis. The venc should be at 45cm/sec.. If the patient has increased serum creatinine or low cardiac output, the venc should be decreased to 30 cm.

Series 6: Axial 2D TOF

This is an optional sequence commonly performed in axial plane occasionally coronal plane it provides T1 weighted post gadolinium images to assess the pelvis for abnormal enhancement or enhancing masses. It also shows venous anatomy.

Filming Instructions:

Billing Instructions:

ICD9 Codes:

Sample Normal Dictation:

The patient was imaged with Coronal SSFSE, Sagittal T1, Axial T2, Coronal 3D dynamic Gd MRA and axial 3D phase contrast pulse sequences. 3D MRA image data was post-processed on a computer workstation to obtain optimized reformations and MIP’s of the vascular anatomy.

A transplant kidney is located in the right iliac fossa with normal size, morphology and cortico-medullary differentiation. There is no hydronephrosis and no perinephritic fluid collections.

The aorta and iliac arteries are of normal caliber with no significant atherosclerotic disease. The transplant renal artery and vein are widely patent with widely patent amostomoses. There is normal enhancement of the transplant renal parenchyma with evidence of excretion of gadolinium into the collecting system on delayed images.

The native renal arteries are small in caliber reflecting decreased flow but no stenosis is identified. No masses are identified in the native kidneys. The cilia, SMA and IMA are all widely patent.

Impression: Normal transplant MRA. No evidence of vascular compromise.