Publication: Renal Biyopsi Yapılan Hastalarda Fibrosis Derecesinin Difüzyon Manyetik Rezonans Görüntüleme ile Ayrımı
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AMAÇ Difüzyon ağırlıklı manyetik rezonans görüntüleme su moleküllerindeki fizyolojik hareketlerin mikroskobik düzeyde görüntülenmesidir. Böbrek, su filtrasyonu, su transportu, reabsorbsiyonu, konsantre ve dilue etme rolü nedeniyle difüzyon MR görüntüleme açısından ilgi çekici bir organdır. Diffüzyon MRG'nin renal fonksiyon ve patolojiler hakkında bilgiler verdiği bilinmektedir. Biz bu çalışmamızda akut veya kronik renal fonksiyon bozukluğu nedeniyle renal biyopsi yapılan hastaların patoloji sonuçlarının şiddeti ve tübülointerstisyel fibrosis düzeyi ile DAG bulgularının korelasyonunu değerlendirmeyi amaçladık. Ayrıca renal fonksiyonu GFR aracılığıyla değerlendirerek ADC ile korelasyon gösterip göstermediğini değerlendirmeyi amaçladık. GEREÇ ve YÖNTEM Çalışma fakülte etik kurulu tarafından onaylandı. Çalışma retrospektif olduğundan aydınlatılmış onam alınmadı. Nisan 2014 ile Kasım 2014 tarihleri arasında, böbrek biyopsisi işlemi yapılan hastalardan 18 yaş ve üstü olan, ve işlem öncesi veya sonrası 1 ay içerisinde üst abdomen MR ve üst abdomen difüzyon MR çekimi gerçekleştirilen 23 hasta çalışmaya dahil edildi. Tüm hastalara 1.5 tesla MR cihazı (Siemens Magnetom Symphony Quantum, Erlangen, Germany) ile batına yönelik faz dizilimli koil kullanılarak rutin üst abdomen MR ve difüzyon MR incelemesi yapılmıştı Hastaların görüntüleri dışlama kriterleri açısından değerlendirildi. Görüntüler morfolojik açıdan kortikomedüller ayrım ve renal yer kaplayıcı lezyon varlığını içeren ek bulgular açısından değerlendirildi. DA görüntüler teknik açıdan değerlendirildi. ROI'ler biyopsi yapılan böbreğin tümünü içeren kortikomedüller (biyopsi ADC), üst-orta zon bileşkesi, orta zon santral ve alt-orta zon bileşkesi kortikomedüller alanı içeren yuvarlak ROI'lerin ortalaması (orta zon ADC) ve her iki böbrek kortikomedüller alanı kapsayan (ADC-GFR) olmak üzere elde olunmuştur. GFR hesaplanması serum kreatinin düzeyinden elde olunan MDRD formülü ile yapıldı. Hastalar KDIOQ evrelemesine göre 5 gruba ayrılmıştır. Patolojik skorlama sistemi; glomerüler hasar, tübülointerstisyel hasar ve vasküler etkilenme kriterlerini içermektedir. Patolojik skor grubuna göre hastalar 3 gruba, tübülointerstisyel fibrosis düzeyine göre 4 gruba ayrıldı. İstatistiksel değerlendirmede; 'Biyopsi ADC' ve 'Orta zon ADC' patolojik gruplar bakımından tek yönlü varyans analizi testi (ANOVA) ile karşılaştırıldı. 'Biyopsi ADC' ve 'Orta zon ADC' ile patolojik skor arasındaki ilişkiye Pearson korelasyon testi ile bakıldı. 'Biyopsi ADC', tübülointerstisyel fibrosis grupları bakımından tek yönlü varyans analizi (ANOVA) ile karşılaştırıldı. 'Biyopsi ADC' ile tübülointerstisyel fibrosis yüzdeleri arasındaki ilişkiye Spearman korelasyon testi ile bakıldı. 'ADC-GFR' GFR grupları bakımından tek yönlü varyans analizi (ANOVA) ile karşılaştırıldı. 'ADC-GFR' ile GFR arasındaki ilişkiye Pearson korelasyon testi ile bakıldı. BULGULAR Morfolojik değerlendirmede; hastaların 9'unda kortikomedüller ayrım normal iken, 8'inde azalmış, 3'ünde ise kaybolmuş olarak izlendi. 9 hastada unilateral ve bilateral değişik boyutlarda benign kistik lezyonlar mevcuttu. Bunlara ek olarak renal ve perirenal ek bulgu olarak 1 hastada alt zon komşuluğunda 5X5 cm boyutlu hematom, 1 hastada ise perirenal çizgilenmeler mevcuttu. Biyopsi ADC, patolojik gruplar arasında istatistiksel olarak anlamlı bir fark saptandı (p=0,005). Post Hoc testlerde farkın hafif ve ileri gruptan kaynaklandığı saptandı (p=0,007). Diğer gruplar arasında (hafif-orta; 0,055; orta-ileri; 0,918) anlamlı fark saptanmadı. Patolojik skor ve biyopsi ADC arasında negatif Yönde 'İyi Derecede' anlamlı korelasyon saptandı (korelasyon katsayısı= -0,615, p=0,004). Orta pol ADC ile patoloji skor grupları arasında istatistiksel olarak anlamlı bir fark saptandı (p=0,014). Post Hoc testlerde farkın 1. ve 3. gruptan kaynaklandığı saptandı (p=0,030). Diğer gruplar arasında (hafif-orta; 0,93; orta-ileri; 0,984) anlamlı fark saptanmadı. Orta zon ADC ile patoloji skoru arasında negatif yönde 'Orta Derecede' anlamlı korelasyon saptandı (korelasyon katsayısı= -0,563, p=0,01). Biyopsi ADC, tübülointerstisyel fibrosis grupları arasında istatistiksel olarak anlamlı bir fark saptandı (p=0,005). Post Hoc testlerde farkın normal derecede fibrosis ile orta derecede ve ileri derecede fibrosis olan gruplar arasından kaynaklandığı saptandı (p=0,021 ve p=0,049). Diğer gruplar arasında (normal-hafif; 1; hafif-orta; 0,057; hafif-ileri; 0,093; orta-ileri; 1) anlamlı farklılık saptanmadı. Biyopsi ADC ile fibrosis yüzdeleri arasında negatif yönde 'Çok iyi derecede' anlamlı korelasyon saptandı (korelasyon katsayısı= -0,770, p<0,001). ADC-GFR, tahmini GFR grupları arasında istatistiksel olarak anlamlı bir fark saptanmadı (p=0,081). ADC-GFR ile tahmini GFR sayıları arasındaki herhangi bir ilişki saptanmadı. SONUÇ Renal difüzyon MR, perfüzyon etkisinden arındırılmış b=800 sn/mm2 görüntülerde, hafif derecede patolojik etkilenmesi olan grup ile ileri düzeyde patolojik etkilenmesi olan grup arasında ayırt edici olmuştur. Patoloji skoru ve tübülointerstisyel fibrosis düzeyi ile renal ADC düzeyleri negatif korelasyon göstermektedir. GFR değerleri ile ADC değerleri arasında ilişki saptanmadı. Ayrıca tüm böbrekten yapılan ölçümler, orta polden yapılan ölçümlere göre daha anlamlı bulundu. Sonuçta DAG renal parankimdeki patolojik değişiklikler ve fibrosis düzeyi hakkında bilgi vermektedir. Ancak DAG'nin renal patolojinin değerlendirilmesinde güvenilirliğini saptamak için uygun teknik faktörler sağlanarak, geniş ve prospektif çalışmalara ihtiyaç vardır. Anahtar Kelimeler: Renal, difüzyon, manyetik rezonans görüntüleme, fibrosis, patoloji
Objective The diffusion-weighted magnetic resonance imaging (DWI) is the imaging of the physiological motion of water molecules on a microscopic level. The kidney is an interesting organ in terms of the diffusion MR imaging due to its role of filtrating, transporting, reabsorbing, concentrating and diluting water. Diffusion MRI is known to provide information about the renal functionings and pathologies. In this study, we aimed to evaluate the severity of the pathology results of the patients who received a renal biopsy due to an acute or a chronic renal dysfunction, and also the tubule-interstitial fibrosis level along with the correlation of DWI findings. Separately, we also aimed to evaluate the renal functioning through GFR to see whether it showed a correlation with ADC or not. Material and Method The study was approved by the ethical committee of the faculty. No informed consent was received since the study was retrospective. Among the patients who received a renal biopsy procedure between April 2014 and November 2014, 23 patients aged 18 and above on whom upper abdominal MR and upper abdominal diffusion MR imagings were performed prior to the process in question or within one month after the process were incorporated into the study. All the patients had received a routine upper abdominal MR and diffusion MR examinations by using a phased-array coil for the abdomen via 1.5 Tesla MR device (Siemens Magnetom Symphony Quantum, Erlangen, Germany). The patients' MR images were evaluated in terms of the exclusion criteria. The MR images were evaluated in terms of the additional findings comprising, morphologically, the corticomedullary differentiation and the presence of renal space occupying lesion. The DW images were evaluated in terms of the technique. ROIs were obtained as those covering the corticomedullary region including the whole kidney on which a biopsy was performed (biopsy ADC), uppermedium zone junction, the average of round ROIs covering the corticomedullary region of the medium zone central region and lower-medium zone junction (medium zone ADC) and those covering the corticomedullary region of both kidneys (ADCGFR). The GFR assessment was performed through the MDRD formula obtained from the serum creatinine level. The patients were separated into 5 groups according to KDIOQ staging procedure. The pathological scoring system comprises the criteria, such as glomerular damage, the tubule-interstitial damage and vascular effect. The patients were separated into 3 groups according to the pathological score group and also into 4 groups according to the tubule-interstitial fibrosis level. In the stratistical analysis, ''Biopsy ADC'' and ''Medium-zone ADC'' were compared via One-Way variance analysis test (ANOVA) in terms of pathological groups. The relationship between '' Biopsy ADC''-''Medium-zone ADC'' and the pathological scoring was examined through Pearson's correlation test. 'Biopsy ADC' was compared via Oneway variance analysis (ANOVA) in terms of the tubule-interstitial fibrosis groups. The relationship between 'Biopsy ADC' and the tubule-interstitial fibrosis percentages was examined through the Spearman's correlation test. The 'ADC-GFR' was compared via One-way variance analysis (ANOVA) in terms of GFR groups. The relationship between 'ADC-GFR' and GFR was examined through Pearson's correlation test. Findings In the morphological evaluation, the corticomedullary differentiation in 9 of the patients was normal, whereas it was monitored to have decreased in 8 of them and even disappeared in 3 of them. There were unilateral and bilateral benign cyctic lesions in various sizes in 9 of the patients. In addition, as the renal and perirenal additional finding, there was a hematoma, 5x5 cm in size, in the lower zone vicinity in 1 of the patients and also perirenal streakings in 1 of the patients. In the biopsy ADC, a statistically significant difference was determined among the pathological groups (p=0,005). In Post Hoc tests, the difference was determined to have originated from mild and severe groups (p=0,007). No significant difference was determined among the other groups (mild-moderate; 0,055; moderate-severe; 0,918). There was a ''Good'' significant correlation in a negative direction determined between the pathological scoring and the biopsy ADC (correlation coefficient = - 0,615, p=0,004). A statistically significant difference was determined between the mid-pole ADC and the pathological scoring groups (p=0,014). In the Post Hoc tests, the difference was determined to have resulted from the 1st and 3rd groups (p=0,030). No significant difference was determined among the other groups (mild-moderate; 0,093; moderate-severe; 0,984). There was a 'Moderately' significant correlation in a negative direction determined between the mid-zone ADC and the pathological scoring (correlation coefficient= -0,563, p=0,01). Between the biopsy ADC and tubule-interstitial fibrosis groups was a significant difference determined (p=0,005). In the Post Hoc tests, the difference was determined to have resulted from the groups with normal fibrosis as well as moderate and severe fibrosis (p=0,021 and p=0,049). No significant difference was ascertained among the other groups (normal-mild; 1; mild-moderate; 0,057; mild-severe; 0,093; moderate-severe; 1). There was a ''Very Well'' significant correlation in a negative direction between the biopsy ADC and fibrosis percentages (correlation coefficient = -0,770, p<0,001). Along with ADCGFR, there was no statistically significant difference among the estimated GFR groups (p=0,081). There was no relationship between ADC-GFR and the estimated GFR numbers, either. Result In the b=800 sn/mm2 images refined from the perfusion effect, the renal diffusion MR has been distinctive between the group with a mild pathological impact and that with a severe pathological impact. The pathological scoring and tubule-interstitial fibrosis level as well as the renal ADC levels show a negative correlation. No relationship was determined between the GFR and ADC values. Moreover, the measurements performed on the whole kidney were found to be more significant than those performed on the mid-pole. In conclusion, diffusion MRI gives information about pathological differences in renal paranchyma and fibrosis. But to determine the reliability of DWI in assessing renal pathology, providing appropriate technical factors, wide and prospective studies must be done. Key Words: Renal, diffusion, magnetic resonance imaging, fibrosis, pathology.
Objective The diffusion-weighted magnetic resonance imaging (DWI) is the imaging of the physiological motion of water molecules on a microscopic level. The kidney is an interesting organ in terms of the diffusion MR imaging due to its role of filtrating, transporting, reabsorbing, concentrating and diluting water. Diffusion MRI is known to provide information about the renal functionings and pathologies. In this study, we aimed to evaluate the severity of the pathology results of the patients who received a renal biopsy due to an acute or a chronic renal dysfunction, and also the tubule-interstitial fibrosis level along with the correlation of DWI findings. Separately, we also aimed to evaluate the renal functioning through GFR to see whether it showed a correlation with ADC or not. Material and Method The study was approved by the ethical committee of the faculty. No informed consent was received since the study was retrospective. Among the patients who received a renal biopsy procedure between April 2014 and November 2014, 23 patients aged 18 and above on whom upper abdominal MR and upper abdominal diffusion MR imagings were performed prior to the process in question or within one month after the process were incorporated into the study. All the patients had received a routine upper abdominal MR and diffusion MR examinations by using a phased-array coil for the abdomen via 1.5 Tesla MR device (Siemens Magnetom Symphony Quantum, Erlangen, Germany). The patients' MR images were evaluated in terms of the exclusion criteria. The MR images were evaluated in terms of the additional findings comprising, morphologically, the corticomedullary differentiation and the presence of renal space occupying lesion. The DW images were evaluated in terms of the technique. ROIs were obtained as those covering the corticomedullary region including the whole kidney on which a biopsy was performed (biopsy ADC), uppermedium zone junction, the average of round ROIs covering the corticomedullary region of the medium zone central region and lower-medium zone junction (medium zone ADC) and those covering the corticomedullary region of both kidneys (ADCGFR). The GFR assessment was performed through the MDRD formula obtained from the serum creatinine level. The patients were separated into 5 groups according to KDIOQ staging procedure. The pathological scoring system comprises the criteria, such as glomerular damage, the tubule-interstitial damage and vascular effect. The patients were separated into 3 groups according to the pathological score group and also into 4 groups according to the tubule-interstitial fibrosis level. In the stratistical analysis, ''Biopsy ADC'' and ''Medium-zone ADC'' were compared via One-Way variance analysis test (ANOVA) in terms of pathological groups. The relationship between '' Biopsy ADC''-''Medium-zone ADC'' and the pathological scoring was examined through Pearson's correlation test. 'Biopsy ADC' was compared via Oneway variance analysis (ANOVA) in terms of the tubule-interstitial fibrosis groups. The relationship between 'Biopsy ADC' and the tubule-interstitial fibrosis percentages was examined through the Spearman's correlation test. The 'ADC-GFR' was compared via One-way variance analysis (ANOVA) in terms of GFR groups. The relationship between 'ADC-GFR' and GFR was examined through Pearson's correlation test. Findings In the morphological evaluation, the corticomedullary differentiation in 9 of the patients was normal, whereas it was monitored to have decreased in 8 of them and even disappeared in 3 of them. There were unilateral and bilateral benign cyctic lesions in various sizes in 9 of the patients. In addition, as the renal and perirenal additional finding, there was a hematoma, 5x5 cm in size, in the lower zone vicinity in 1 of the patients and also perirenal streakings in 1 of the patients. In the biopsy ADC, a statistically significant difference was determined among the pathological groups (p=0,005). In Post Hoc tests, the difference was determined to have originated from mild and severe groups (p=0,007). No significant difference was determined among the other groups (mild-moderate; 0,055; moderate-severe; 0,918). There was a ''Good'' significant correlation in a negative direction determined between the pathological scoring and the biopsy ADC (correlation coefficient = - 0,615, p=0,004). A statistically significant difference was determined between the mid-pole ADC and the pathological scoring groups (p=0,014). In the Post Hoc tests, the difference was determined to have resulted from the 1st and 3rd groups (p=0,030). No significant difference was determined among the other groups (mild-moderate; 0,093; moderate-severe; 0,984). There was a 'Moderately' significant correlation in a negative direction determined between the mid-zone ADC and the pathological scoring (correlation coefficient= -0,563, p=0,01). Between the biopsy ADC and tubule-interstitial fibrosis groups was a significant difference determined (p=0,005). In the Post Hoc tests, the difference was determined to have resulted from the groups with normal fibrosis as well as moderate and severe fibrosis (p=0,021 and p=0,049). No significant difference was ascertained among the other groups (normal-mild; 1; mild-moderate; 0,057; mild-severe; 0,093; moderate-severe; 1). There was a ''Very Well'' significant correlation in a negative direction between the biopsy ADC and fibrosis percentages (correlation coefficient = -0,770, p<0,001). Along with ADCGFR, there was no statistically significant difference among the estimated GFR groups (p=0,081). There was no relationship between ADC-GFR and the estimated GFR numbers, either. Result In the b=800 sn/mm2 images refined from the perfusion effect, the renal diffusion MR has been distinctive between the group with a mild pathological impact and that with a severe pathological impact. The pathological scoring and tubule-interstitial fibrosis level as well as the renal ADC levels show a negative correlation. No relationship was determined between the GFR and ADC values. Moreover, the measurements performed on the whole kidney were found to be more significant than those performed on the mid-pole. In conclusion, diffusion MRI gives information about pathological differences in renal paranchyma and fibrosis. But to determine the reliability of DWI in assessing renal pathology, providing appropriate technical factors, wide and prospective studies must be done. Key Words: Renal, diffusion, magnetic resonance imaging, fibrosis, pathology.
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Tez (tıpta uzmanlık) -- Ondokuz Mayıs Üniversitesi, 2015
Libra Kayıt No: 113891
Libra Kayıt No: 113891
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