2012 Sixth International Conference on Complex, Intelligent, and Software Intensive Systems

Ultrasonography Image Analysis for Detection and Classification of Chronic Kidney Disease
Chih-Yin Ho, Tun-Wen Pai*, Yuan-Chi Peng Dept. of Computer Science and Engineering, National Taiwan Ocean Univ., Keelung, Taiwan, * twp @ ntou.edu.tw Chien-Hung Lee*, Yung-Chih Chen, Yang-Ting Chen, Kuo-Su Chen Chang-Gung Memorial Hospital, Keelung, Taiwan * tmh2856 @ yahoo.com.tw

Abstract More than 5% of adults suffer from different types of kidney disease, and millions of people die prematurely from cardiovascular diseases associated with chronic kidney disease (CKD) in each year. The best way to reduce death caused by kidney disease is early prophylaxis and treatment, and which could be achieved through accurate and reliable diagnoses at the early stage. Among various diagnostic methods, ultrasonographic diagnosis is a low-cost, convenient, noninvasive, and timeliness method. Most importantly, this type inspection would not cause extra burden for patients who suffer kidney diseases. This paper presents a computer-aided diagnosis tool based on analyzing ultrasonography images, and the developed system could detect and classify different stages of CKD. The image processing techniques focus on detecting the atrophy of kidney and the proportion of fibrosis conditions within kidney tissues. The system includes image inpainting, noise filtering, contour detection, local contrast enhancement, tissue clustering, and quantitative indicator measuring for distinguishing various stages of CKD. This study has collected thousands of ultrasonic images from patients with kidney diseases, and the selected representative CKD images were applied to be pre-analyzed and trained for comparison. The calculated transition locations as reference indicators could provide physicians an auxiliary and objective computer-aid diagnosis tool for CKD identification and classification. Keywords- ultrasonography image; chronic kidney disease (CKD); image inpainting; K-means clustering; total variation filter

I.

INTRODUCTION

More than 500 million persons worldwide suffer various forms of kidney damage [1], and the incidence of end-stage renal disease (ESRD) is still increasing in different countries. To maintain the life of patient at ESRD period, dialysis or transplant is the ultimate way of therapy. According to the statistics, the fastest growing dialysis populations are in Asia and Latin America with a range of 7-10%, while in United States, Europe and Japan are increasing with rates of 3-4%. Up to end of 2009, there are approximately 1.9 million patients estimated to be on dialysis treatment [2]. Especially, the statistical report of United States Renal Data System (USRDS) in 2009 has shown that the dialysis incidence rate in Taiwan ranked at the first position in five consecutive years. The prevalence rate of ESRD patients has surpassed Japan and the incidence rate has exceeded the
978-0-7695-4687-2/12 $26.00 2012 IEEE DOI 10.1109/CISIS.2012.180 624

United States and ranking as the first in the world since 2008 [3]. Unfortunately, more than 40% of Taiwanese patients with kidney diseases do not know that they are already suffering kidney diseases according to the survey by Bureau of National Health Insurance in Taiwan. It is mainly due to no significant symptom at early stages of chronic kidney disease (CKD), or sometimes the symptoms are easily misdiagnosed as colds or other diseases. Hence, after a period of time, the serious symptoms are suddenly exploded at its ending stages. Patients with CKD normally show with the symptoms of loss of appetite, fatigue, insomnia, dizziness, and yet these features are not specific symptoms for CKDs. Hence, adopting an auxiliary computer-aided diagnosis through ultrasonography image inspection can provide non-invasive observation and which help to detect the damaged kidneys without causing any extra burden for patients. Ultrasonography diagnosis has the advantages of non-invasive, low-cost, convenient, reproducible, radiation-free, and timeliness properties. Inspected images could denote the ambiguous boundaries and size of kidneys and blurred textures between renal pelvis and parenchyma. In addition, it could help to diagnose kidney calculus, hydronephrosis, nepehritis, tumor, abnormal conditions of anatomical structures, and deformed morphology of both kidneys [4]. Although ultrasonic photography is useful for medical pathology analysis, realtime monitoring and prognosis of care planning, the inspected images contain annoyed multiplicative noises caused by sonic signals degraded by electromagnetic interferences during transmission, conversion, and collection procedures. These multiplicative noises sometimes lead to inconsistent diagnoses by medical doctors and even delay the best timing for pertinent treatment. The main goal of this study is to provide a consistent and stable indicator to detect and identify different stages of CKD. Data collection of renal ultrasound images for evaluating performance of the proposed system and the trained CKD reference indicators will be discussed here. Through observing and comparing the size of kidneys, thickness of renal pelvis and parenchyma, and fibrosis condition compared to reference indicators, a physician can consistently diagnose the kidney disease and identify the stage of CKD under the support of quantitative measurements.

II.

SYSTEM CONFIGURATION AND IMAGE DATABASE

The collected ultrasonic image dataset contains more than 3000 anonymous images which are clinical samples of CKD patients from Chung-Gung Memorial Hospital (Keelung, Taiwan), and the collecting plan is under approval by Taiwan Association of Institutional Review Board (TAIRB) (Approved Number CGMHIRB 99-0029B). All personal information does not retain on images and the purpose of these collected dataset only for clinical therapy and academic research. The imaged are clustered into six classes including one normal group and five different stages of CKD symptoms. Furthermore, all patients with CKD are further examined and see if the patient holds diabetes symptoms simultaneously. The developed auxiliary diagnosis system is shown in Figure 1, which includes image pre-processing module, K-means clustering, texture detection of renal pelvis and parenchyma, and measurement of transition indicator analysis. In the pre-processing module, two main tasks are achieved, including removal of annotated marks by physicians and filtering of embedded noises. Those empty locations caused by mark removal are re-filled by in-painting techniques, and the multiplicative noise is filtered by a total variation filter. Both tasks in the pre-processing are designed for improving the accuracy of boundary detection between renal pelvis and parenchyma. Due to the limitations of low quality of ultrasonic images, a completely automatic diagnosis system is not yet achievable. Hence, the first step of selecting regions of interest (ROI) is done by manual assistance, and which will successfully increase the rates of correct detection. In the second module, a K-means clustering technique is performed to detect the regions of renal pelvis and parenchyma. This module proposed here is mainly due to low resolution of ultrasonic image and spatial-dependant dispersion effects that cause failure of global parameter settings. Hence, an approach by local segmentation for an ultrasonic image is proposed here. The K-means clustering is designed to dynamically segment the ROIs into five local parts, and the boundaries between renal pelvis and parenchyma can be observed. Finally, according to the detected most outer contour of a kidney, a set of concentric boundaries can be defined inwardly. In each equally distributed interval within the kidney, the binarized pixels located within the ultrasonic image reflect the tissue conditions of renal pelvis and parenchyma. According to our observations, the tissue pixels located within renal pelvis have a tendency to be lighter graylevels and which are binarized into white pixels, while the tissue pixels located within renal parenchyma have a tendency to be darker graylevels and those pixels are binarized into black pixels. Therefore, we can evaluate the ratios of black and white pixels to indicate the proportions of distributed tissues of renal pelvis and parenchyma in each defined interval. According to the spatial distribution of white-toblack pixel ratio, we can easily indicate the various stages of CKD patients. All details will be discussed in the following sections.

Ultrasonographic Images

Image Pre-Processing Image Inpainting

Noise Filtering

Kidney Outer Contour Designation

K-means Clustering Region Detection

Concentric Contour Detection Transition Indicator Measurement

CKD stage Identification

Figure 1. System configuration of the proposed detection system.

III.

SYSTEM MODULE DESCRIPTION

A. Image pre-processing : inpainting techniques An input ultrasonic image might contain significant markers by medical doctors and/or system labeling. Though the diagnosis labeling and measuring markers annotated by physicians could provide rough initial locations of a kidney, these apparent markers also influence the results of boundary detection when they are not removed in advance. For examples in Figure 2 and 3, original input images might remain standard system information and the green markers were labeled by physicians. These markers should be removed prior to boundary detection. Therefore, the first step in pre-processing module is to detect and remove the markers automatically. The markers can be successfully detected due to their constant graylevels and highly differentiated graylevels among neighboring pixels. After identifying and eliminating the artificial points, the left empty spots should be repaired and restored by certain

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inpainting techniques. In this paper, we a adopted the Fast Marching Method (FMM) as the inpainting g procedures. The FMM algorithm provides efficient and eff fective inpainting results for our ultrasonic images, which com mpletes repairing tasks by filling blank regions from outer areas to central parts progressively according to the graylevels of known image pixels close to the target regions. In this study, a first order approximation was applied to the o originally known image areas with a normalized weighting fu unction, the detail algorithms can be referred to the FMM pap per [5]. Figure 2 shows an original image and its correspo onding inpainted rs annotated by image after removing the spatial marker medical doctors. The repaired image is then n considered as a query image obtained from ultrasonic machine directly.

(a)

(a)

(b) )

Figure 2: (a) An original input image; (b) marker re emoval and inpainted image by FMM approaches.

B. Image pre-processing : noise filtering Though the ultrasound imaging techn niques are well established in medical applications with sev veral advantages, the degraded qualities of observed ima ages also cause ambiguities for physicians and patients s to distinguish pathological and normal scanned tissue es. A medical ultrasonic image usually inherit with speckl le noise with low resultion and which may lead inaccurat te detection and sometimes cause inconsistent diagnose es by different medical doctors [6]. Hence, to design a s suitable filter for supressing speckle noises at the beginnin ng is always an important task for developing an auxililary diagnosis system. In this study, the region detection between n renal pelvis and parenchyma is our main purpose. Hence, , very fine local texture distributions are not considered as s the preliminary requirements. Contrastly, a higher level distinguishment between two different types of tissues s are enhanced. According to these specifications, a noise r removing filter is designed based on the total variation a approach in this study[7]. On the other words, a total variati ion minimization algorithm is applied to sovle the image den noising problem. This type noise filtering method normally y preserves sharp edges and local textures, lower down signa al-to-noise ratios, and remove granular speckle noise substan ntially. It indeed facilitates the boundary detection in the n next modules. In Figure 3, an original noisy image was filtered by the variational approach and the result has shown a clearer image without granular speckle noise.

(b) ering processes. (a) An original Figure 3: An example of total variation filte image;(b) filtered results.

C. K-means clustering for region se egmentation It is observed that the cen ntral part of one snapshot of an ultrasound image holds hig gher resolution than both sides. This is due to the ultrasound beam impinges on the reflecting interface at a right t angle. According to the Physics principles, for an in ncidence angle on any interface, the reflected ultrasou und beam will leave the interface at an identical angle as the incidence angle. Hence, when taking a snapshot at a certain aspect during kidney inspection, the detected ultrasound energy from reflected beams will be degrade ed if the ultrasound beam strikes the interface at an angle larger l than certain degree from perpendicular. To face th his condition, a straight forward K-means clustering tec chnique is proposed here to segment the ROIs into several different local regions according to its neighboring gr raylevel distributions [8]. In other words, if one emplo oys a globally identical thresholding parameter to execute binarization procedures on an observed ultra asound kidney image, the true boundaries located on diffe erent locations could not be equivalently detected at any detecting point. Therefore, dynamic thresholdin ng settings for different angle aspects are important for r extracting the accurate contours at different portions. Here, H an ultrasound image is initially divided into 5 subparts symmetrically per, and lower parts. The including central, left, right, upp

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central part is assumed as the tissues of renal pelvis with lighter pixels, while the left four section ns are assumed as tissues of renal parenchyma with dark ker pixels. After performing the K-means algorithm with h 5 initial points, the kidney image can be clustered into 5 groups iteratively. An example of K-means clustering on an ultrasound kidney image is shown in Fig gure 4, where the initial points were set at the center poin nt and the other 4 positions located at the outer boundar ry vertically and horizontally. In Figure 4, the pixel gro oup with lightest graylevel located in the center position i is consider as the ur darker groups tissues of renal pelvis and the other fou are identified as the tissues locate ed within renal parenchyma. It can be noticed the bound daries can also be identified through the region segmentation algorithms.

chyma by K-means Figure 4. Identified renal pelvis and parenc clustering algorithms. The left image is the origina al image with 5 initial points and the right one is its segmented result ts. The lightest pixel group is considered as the tissues for renal pelvi is and the other four groups as the tissues for renal parenchyma.

IV.

SPATIAL PROPORTION OF RENAL L PELVIS AND

PARENCHYMA

h as chronic Diagnosis of kidney diseases such glomerulonephritis, hypertensive nephropa athy and diabetic nephropathy usually depends on the observations of damaged conditions on renal parenchym ma as common pathological features. In general, the deterio oration of kidney diseases from an initial stage to function fa ailure completely, the observed symptoms from ultrasou und images are shrinking sizes of atrophied kidneys, decre eased proportions of renal parenchyma, and the increasing g ambiguities of boundaries of renal cortex and medulla. Th herefore, through measuring the boundaries of renal pelvis and parenchyma from an ultrasound image and estimating i its corresponding spatial proportion can facilitate medical doc ctors to diagnose the symptoms of CKD and discriminate dif fferent stages for patients. Since the fibrosis conditions in re enal parenchyma are distributed unevenly from inner to o outer parts of a kidney, the identified tissue proportion of renal pelvis and parenchyma at different locations can be e calculated and formed as a simple indicator for CKD d diagnosis. In this study, the whole kidney is equally sep parated into 10 concentric contours from the outside shape of kidney inwardly. In each concentric segment, the e pixel value for can be assigned tissues of renal pelvis and parenchyma c according to previous clustering procedur res. Accordingly, the white-to-black ratios of all 10 concentric c contours can be obtained and sketched. The white-to-black ratios should be large at inner contours than the outer cont tours, and a ratio

which approximates to unity should d occur near the transition boundary of renal pelvis and paren nchyma. The ratio curve is drew on an x-axis according to it i spatial locations, and it can be expected that different stages of CKD reflect different spatial proportions at diffe erent concentric contours. The value of white-to-black ratios from larger than one to less than one can be considered as a transition indicator from renal pelvis to parenchyma te extures, and the location represents the rough boundaries between b the renal pelvis and parenchyma within an atrop phied kidney. Since the kidney is equally distributed into 10 0 concentric contours, the proportional indicator is size indepe endent. In addition to the spatial indicator of white-to-black k ratio, the real size of inspected kidney is also shown on the same plot. Hence, a medical doctor can evaluate the true e size of patients kidney simultaneously. For equivalently segmenting the kidney object, the 10 concentric contours of equal intervals were obtained by employing mathematic cal morphology operators iteratively. A morphological erosion n filter with a 3x3 square structuring element was applied to o the originally detected kidney, and the different pixels between the original kidney acted and assigned as the and newly eroded image was extra first E1 pixel set. Followed by the e same erosion operation with the identical structuring element e on the eroded boundary, the subtracted pixel set from the second erosion operation was assigned within th he second E2 pixel set. Identical procedures were continua ally performed until the kidney object vanished. Different sizes of kidney will be divided into different total number of o layers. To simplify the concentric contour analysis and a reduce sensitive measurements, 10 equal intervals were set as the default parameters according to the experi imental trials. According to the real size measured from the ultrasound u machine, each width of 10 intervals can be precise ely evaluated. Hence, the location of true intersection bounda aries between renal pelvis and parenchyma can be detected and sketched. Examples of spatial proportion curves of whit te-to-black values for 5 different stages of CKD are shown in left column of Figure 5. Each plot contains six patients diagnosed with an identical stage of CKD by at least t two medical doctors in Chung-Gung Memorial Hospital sim multaneously. The upper X-coordinate in each plot represen nts the real measurement of a kidney in millimeter, and righ htest point represents the center of kidney and the leftmost t point indicates the left boundary of a kidney. The lowe er coordinate shows the equally distributed intervals of 10 concentric contours, and the direction is the same as the upper X-axis. The location of 10th interval represents the cent ter of kidney and the 1st layer indicates the most outside boundary interval of a kidney. The Y-axis represents the value of white-to-black ratio in each segment. For the com mparison of five different stages of CKD, the ratio of unity y, transition indicator of white-to-black ratio, located at 8.9, 7.5, 7.2, 6.8, and 6.6 on Y-coordinate for five increasing stages s averagely and the average locations are shown by bold d vertical lines. The sizes of the kidney can be observed on th he upper X-axis for each

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patient (measured from leftmost boundary to center). Generally speaking, near the outside layer of kidney, the white-to-black ratio is low due to the reason that black pixels dominate the tissues within renal parenchyma. In contrast, the regions located near center area, the tissues in renal pelvis are dominated by white pixels and the white-toblack ration is relatively high. Figure 5 indicated the five different stages of CKD patients and their distributions of transition indicators. The ESRD patients are located in the most left location, while the CKD patients with the first stage conditions are relatively located on the right part. Six selected images from each different stage of CKD patients and their corresponding detected boundaries are shown in the right three columns of Figure 5. It can be observed that ranges of transition indicator for different stages of CKD patients are overlapped in certain level. However, the tendency of transition indicators obviously move to left when the damage conditions of CKD patients are getting serious. Hence, the calculated value of transition indicator can be applied to diagnose and classify the stage of CKD patients under a consistent approach. V. RESULTS AND DISCUSSIONS

borders between renal pelvis and parenchyma. However, after applying the combination of imaging preprocessing and region clustering algorithms in this study, the pixels of normal/fibrosis tissues and relative proportion can be identified in a consistent way. The novel auxiliary system based on a quantitative indicator is proposed here to facilitate physicians diagnosing CKD stage and follow-up comparisons. The results reported here are still at its very early stage of clinical study. Comprehensive studies on all collected images associated with blood/urine inspection will be continuously conducted, and it can be expected that a statistical analysis of quantitative measurement of the transition indicator can be applied as a standard reference for classifying various stages of CKD in the near future. ACKNOWLEDGMENT The project is supported by National Taiwan Ocean University (NTOU 99529001K to T.W. Pai) and Keelung Chang-Gung Memorial Hospital (CMRPG 290191 to C.-H. Lee and Y.-C. Chen ).

The main goal of this preliminary study is to discover an efficient and effective indicator which can assist physicians to identify different stages of CKD. Thousands of clinical images were obtained from Chang-Gung Memorial Hospital and a corresponding imaging database was constructed for a long term follow-up study and clinical treatment. To enhance the proposed indicator being feasible for CKD classification, 30 clinical images acquired from 30 different patients were selected and analyzed from the constructed database. These images were captured from the same angle and diagnosed/classified as five different stages of CKD. Though these ultrasonic images degraded by multiplicative noise are blurred in low resolution, observation from the clinical images has clearly shown that the transition locations of white-to-black ratio within a renal organ are proportional to the stages of CKD patients. The patients with earlier stages of CKD possess higher values of whiteto-black transition indicator than the patients at his/her ending stages. It is not an easy job to precisely identify the

REFERENCES
[1] http : //www .worldkidneyday. org / , accessed Jan. 2012. [2] Meichelboeck W, End Stage Renal Disease (ESRD) Epidemiolog Where are we going ?, 7th International Congress of the Vascular Access Society, 2011. [3] UNITED STATES RENAL DATA SYSTEM : http : //www .usrds. org/ , accessed Jan. 2012. [4] W. Charles ONeill, Atlas of Renal Ultrasonography, Chapter 2, p1119, 2001 [5] Alexandru Telea, "An Image Inpainting Technique Based on the Fast Marching Method," Eindhoven University of Technology,Vol. 9, No. 1: 2536. [6] S.K. Narayanan and R.S.D.Wahidabanu , "A View on Despeckling in Ultrasound Imaging, " International Journal of Signal Processing, Image Processing and Pattern Recognition ,vol. 2, no. 3, pp . 85-98 , Sep. 2009. [7] G. Gilboa, N. Sochen, and Y. Y. Zeevi, Texture preserving variational denoising using an adaptive fidelity term , IEEE Transactions on Image Processing, vol. 15, no. 8, pp. 2281-2289, 2006. [8] Amorim, R. C.; Mirkin, B (2012). "Minkowski metric, feature weighting and anomalous cluster initializing in K-Means clustering". Pattern Recognition 45 (3): 10611075.

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1st stage CKD Avg. transition indicator = 8.9

Center Location

Center Location

2nd stage CKD Avg. transition indicator = 7.5

Center Location

3rd stage CKD Avg. transition indicator = 7.2

Center Location

4th stage Avg. transition indicator = 6.8

Center Location

5th stage CKD Avg. transition indicator = 6.6)

Center Location Figure 5. Five plots in left column represent the white-to-black ratio curve for different stages of CKD patients. Average transition indicators from 6 different CKD patients with an identical stage are shown in bold vertical lines. The images on right three columns show one of the selected ultrasonic images from each CKD group and their detected various textures in renal pelvis and parenchyma respectively.

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