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Vouji chi squarel18.No.2August 2023

Original Research p-ISSN 1829-7005e-ISSN2540-8836

MORPHOLOGICAL PROFILE OF KIDNEY ULTRASONOGRAPHY

EXAMINATION FOR PERSISTENT AND TRANSIENT CASES OF
ACUTE KIDNEY INJURY (AKI) IN CHILDREN AT Dr. Hospital.
SOETOMO

Candra Harmindasatya1*, Lenny Violetta2, Rosy Setiawati2

1
Radiology Specialist Study Program, Faculty of Medicine, Airlangga University, Dr
Soetomo Teaching Hospital Surabaya, Indonesia.
2
Department of Radiology, Faculty of Medicine, Airlangga University, Dr Soetomo
Teaching Hospital Surabaya, Indonesia.
Correspondence Address: Candra Harmindasatya.
E-mail:

ABSTRACT
Introduction:During the COVID-19 pandemic, especially in 2022, 189 cases of Atypical
Progressive Acute Kidney Injury (AKI) were recorded in children in Indonesia. A phenomenon
has been discovered where children exposed to COVID-19 accompanied by MIS-C are
significantly more at risk of experiencing AKI. The role of ultrasonography (USG) examination
in children is not only to exclude obstructive disorders of the urinary tract, but also to provide
radiological images of kidney morphology that are in line with the condition of AKI. These
morphological features include an increase in kidney length, echogenicity, volume and thickness
of the kidney parenchyma. In addition to the severity classification (staging), a classification of
AKI types in children has been proposed which is categorized into Persistent and Transient AKI
which refers to recovery time, where recovery is defined as a decrease in a minimum of one
degree of severity according to the KDIGO AKI Staging criteria in less than 72 hours, with these
categories it will be easier to determine management and evaluate the etiology. Aims: This study
aims to determine the correlation between kidney morphology and the incidence of
persistent/transient type classification of AKI in children. Methods:This study used an analytic
observational design with a retrospective approach with the study population being all medical
record data from pediatric patients at Dr Soetomo Hospital Surabaya aged 0-18 years with a
diagnosis of AKI to determine the relationship between persistent/transient AKI and ultrasound
of kidney morphology during the COVID-19 pandemic. 2022.Result:This research shows that
there is a significant correlationbetween persistent/transient AKI type classification groups and
group classification of kidney length (p=0.008), total kidney volume (p=0.008), parenchymal
thickness of the right kidney (p=0.025) and left kidney (p=0.004), classification of renal
parenchymal echogenicity (p=0.029), but there was no significant relationship between the
Persistent/Transient AKI type classification group and the obstructive uropathy picture variable
(p=0.506). Conclusion: There is a significant relationship between the Persistent/Transient AKI
group and kidney morphology, namely in the classification of kidney length, total kidney
volume, and thickness of the kidney parenchyma, classification of renal parenchymal
echogenicity but there was no significant correlation with the variable features of obstructive
uropathy.

Keywords: Persistent/Transient AKI, Kidney Morphology

 INTRODUCTION
In 2022, there was a spike in weekly
confirmed COVID-19 cases with the highest
number of confirmed COVID-19 cases at
64,718 cases. As a result of the spike in
COVID-19 cases, the COVID-19 Handling
Task Force has again issued Circular Letter
Number 20 concerning Health Protocols for
Implementing Large-Scale Activities during
the COVID-19 pandemic, one of the aims of
which is to prevent an increase in COVID-19
transmission.
During this period, there were far more
cases of COVID-19 infection in adults
compared to cases in children, and clinical
symptoms in children were relatively mild
compared to adults, however, COVID-19
infection can develop into a condition called
Multisystem Inflammatory Syndrome. ,
which is a clinical condition that is not often
encountered but is quite serious in sufferers
of COVID-19 infection1-3. Since 2020, the
Center of Disease Control and Prevention
(CDC) recorded 9,455 cases of Multisystem
Inflammatory Syndrome in Children (MIS-C)
during the pandemic, with a total of 78 deaths
worldwide3.
Children with acute COVID-19
infection, accompanied by clinical
manifestations according to MIS-C criteria
are more at risk of experiencing Acute
Kidney Injury (AKI)4, where up to October
2022 there were 189 cases of atypical
progressive acute kidney disorders (Atypical
Progressive AKI) recorded in children in
Indonesia and the majority were aged 1 – 5
years5.
In AKI patients, the role of
ultrasonography (USG) examination is aimed
at eliminating the possibility of obstructive
disorders of the urinary tract (post renal), as
well as providing radiological images of
kidney morphology that can support the
condition of AKI7. In cases of AKI,
ultrasound examination results also report an
increase in length, echogenicity, volume and
thickness of the renal parenchyma8.
Pediatric patients with clinical AKI can
be classified into the categories of Persistent
AKI and Transient AKI. This category
classification refers to the recovery time
where recovery is defined as a reduction of a
minimum of one stage according to the
KDIGO criteria. Thus, it will be more useful
to determine management and evaluate
etiology 4.
From the results of kidney ultrasound
findings, it can provide information on the
morphological component profile and is
expected to strengthen its role in cases of
persistent and transient AKI in pediatric
patients.
METHOD
This study used an analytical observational
design with a retrospective approach. The
research population was all medical record
data of pediatric patients at RSUD Dr.
Soetomo Surabaya aged 0 -18 years with a
diagnosis of AKI based on an increase in
creatinine of at least one point five (1.5) times
the baseline and/or urine production <0.5
cc/kgBW/hour in 6 hours, which is in
accordance with the AKI criteria according to
KDIGO during the period 1 January – 31
December 2022.
The sample for this study is the total
population that meets the inclusion and
exclusion criteria. Inclusion criteria include
patients aged 0-18 years, having a clinical
picture of at least (2) MIS-C criteria according
to WHO and patients with a clinical diagnosis
of AKI who request a kidney ultrasound
examination. Exclusion criteria include the
presence of an established etiology other than
MIS-C (eg: sepsis, shock, hypovolemia,
others).
The research instrument used in the
Kidney Ultrasound examination was a Philips
Ultrasound ClearVue 550 brand ultrasound
aircraft with a 1.8-3.2 MHz Convex probe and
a 5.3 MHz linear probe.
Data analysis in this research uses
quantitative data analysis to determine the
correlation between variables. The Chi-square
correlation test was used to determine the
relationship between the degree of severity
(AKI staging) and the type of persistent and
trendy AKI, as well as to see the relationship
between variables and risk factors. Meanwhile,
the Spearman correlation test was used to
determine the relationship between persistent
and transient AKI cases with the kidney
morphology profile.
In collecting data, researchers have
obtained ethical approval from the Research
Ethics Committee, Faculty of Medicine,
Airlangga University.
RESULTS
Correlation Characteristics and Risk
Factors in Persistent/Transient AKI Cases
with Kidney Length Classification
Variables.
From observationFrom the medical
records of 35 research samples, 30 patients
with AKI and 5 non-AKI patients were
compared. The sizes obtained were compared
with the normal value of kidney length
according to age 21, so that the distribution
of kidney length classification variables was
obtained which can be seen in table 1 below:
Table 1. Distribution of Kidney Length
Classification Variables. kidney by(22.8%), the normal range of
Kidney Kidney Kidney kidney length for the right kidney is (20%)
Length Right Left and the left kidney is (22.8%), then for
n % n % increased kidney length in the right kidney
Decrease 9 25.7% 8 22.8% and left kidney the same value is obtained,
Normal 7 20% 8 22.8% namely (54.3%). ).
Increase 19 54.3% 19 54.3% Furthermore, based on these results, they
Total 35 100% 35 100% were classified into (2) groups, namely
decreased kidney length and normal kidney
Based on the distribution of kidney length group-Increases against reference21,
length classification variables, the results and a cross tabulation was carried out on the
showed that kidney length decreased in the AKI/non AKI classification group and on the
right kidney by (25.7%) and in the left Persistent/Transient AKI classification
group, which can be seen in table 2 below:

Table 2. Contingency of Kidney Length Classification Variables

Right Kidney Left Kidney
Kidney Length Kidney length is Kidney Length Kidney length
Category
Decreases normal-increased Decreases is normal-
increased
Non-AKI (n= 5) 3 (8.6%) 2 (5.7%) 3 (8.6%) 2 (5.7%)
AKI (n=30) 6 (17.1%) 24 (68.6%) 5 (14.3%) 25 (71.4%)
Transient AKI (n=9) 4 (13.3%) 5 (16.6%) 4 (13.3%) 5 (16.6%)
Persistent AKI (n= 21) 2 (6.7%) 19 (63.3%) 1 (3.37%) 20 (66.7%)

Of the 35 research samples, 30 group and obtained a significant positive

patients were found with AKI who then
carried out the Spearman test to determine
the correlation between the kidney length
classification group and the
persistent/transient AKI type classification
correlation test result, namely the right
kidney (p=0.028, correlation coefficient
0.400) and left kidney (p=0.006, correlation
coefficient 0.488).
Correlation Characteristics and Risk be Persistent. AKI as a risk factor is 16 times
Factors in Persistent/Transient AKI Cases more likely to increase the total kidney volume
with Kidney Volume Classification compared to the transient type of AKI.
Variables. Furthermore, based on the Spearman
From observations of 35 research correlation test in the total kidney volume
samples, a comparison of the calculation classification group with the
results obtained was carried out with the persistent/transient AKI type classification
normal value of total kidney volume, then the group, a significant positive correlation test
total kidney volume was classified compared result was obtained (p=0.006, correlation
coefficient 0.488).
with the reference value, and the results were
obtained in table 3 below:
Correlation Characteristics and Risk
Factors in Cases of Persistent/Transient
Table 3. Distribution of Total Classification AKI on Kidney Parenchymal Thickness
Variablesl Kidney Volume. Classification Variables.
Total n %
Kidney
Volume
Decrease 8 25.7% Of the 35 research samples, a comparison
Normal 4 11.4% between the calculations obtained and the
Increase 23 65.7% classification of kidney parenchymal thickness
Total 35 100% can be seen in table 4 below:

Table 4. Distribution of renal parenchymal

Based on the distribution of the total thickness classification variables
kidney volume classification variable, it was Renal Kidney Kidney
found that kidney volume decreased by Parenchy Right Left
(25.7%), normal kidney volume was (11.4%) mal n % n %
and kidney volume was increased by Thickness
(65.7%). Decrease 2 5.7% 3 8.6%
Furthermore, based on these results, Normal 5 14.3% 4 11.4%
they were classified into (2) groups, namely Increase 28 80% 28 80%
decreased kidney volume and normal- Total 35 100% 35 100%
increased kidney volume groups relative to
Based on the distribution of renal
the reference,and a cross tabulation was
parenchymal thickness classification variables,
carried out on the AKI/non AKI
the resulting thickness results decreased by
classification group and on the (5.7%) in the right kidney and (8.6%) in the
Persistent/Transient AKI classification left kidney. Then, for thickness within the
group, which can be seen in table 5 below: normal range, results were obtained as low as
(14.3%) in the right kidney and (11.4%) in the
Category Total Kidney Volume left kidney. Furthermore, in the right kidney
Decreased Kidney and left kidney, it was found that the thickness
Kidney volume is of the kidney parenchyma had increased by
Volume normal- (80%).
increased Furthermore, based on these results, they
Non-AKI 3 (8.6%) 2 (5.7%) were classified into (2) groups, namely groups
(n=5) with decreased/normal renal parenchymal
AKI (n=30) 5 (14.3%) 25 (71.4%) thickness and increased renal parenchymal
Transient 4 (13.3%) 5 (16.7%) thickness relative to the reference., and a cross
AKI (n= 9) tabulation was carried out on the AKI/non
Persistent 1 (3.3%) 20 (66.7) AKI classification group and on the
AKI (n=21) Persistent/Transient AKI classification group,
so that it can be seen in table 5 below:
Of the 35 research samples, 30 patients
were found with AKI, where from the results
of the Chi-Square test in the Classification of
Persistent/Transient AKI Types, there was a
significant relationship with the total kidney
volume classification variable (p=0.008,
OR=16, CI=1.45-176.451) with a tendency to
Table 5. Contingency Classification of Kidney Parenchymal Thickness
Parenchyma Thickness Parenchyma Thickness
Right Kidney Left Kidney
Category
Decreased/ increase Decreased/ increase
normal normal
Non-AKI (n=5) 5 (14.3%) 0 (0%) 4 (11.4%) 1 (2.9%)
AKI (n= 30) 2 (5.7%) 28 (80%) 3 (8.6%) 27 (77.1%)
Transient AKI (n=9) 2 (6.7%) 7 (23.3%) 3 (10%) 6 (20%)
Persistent AKI (n= 21) 0 (0%) 21 (70%) 0 (0%) 21 (70%)
 Of the 35 research samples, 30 table 7 below:
patients were found to have AKI, where from
the results of the Chi-Square test on the
Classification of Persistent/Transient AKI
Types, there was a significant relationship
with the parenchymal thickness classification
variable of the right kidney (p=0.025,
ɑ=0.05) and left kidney (p=0.005, ɑ=0.05).
Furthermore, based on the Spearman
correlation test in the renal parenchymal
thickness classification group with the
persistent/transient AKI type classification
group, significant positive correlation test
results were obtained in the right kidney
(p=0.025, correlation coefficient 0.408) and
left kidney (p=0.004, correlation coefficient
0.509 ).

Correlation Characteristics and Risk

Factors in Cases of Persistent/Transient
AKI on the Kidney Parenchymal
Echogenicity Classification Variable.
Based on 35 samples for observing
the echogenicity of the kidney parenchyma, 3
(three) groups of measurement results were
obtained, namely Hypoechoic, Isoechoic and
Hyperechoic kidney parenchyma. The
distribution of parenchymal echogenicity
classification variables can be seen in table 6
below.

Table 6. Distribution of Renal Parenchymal

Echogenicity Groups
Parenchymal Right Left Kidney
Echogenicity Kidney
Group n % n %
Hypoechoic 5 14.3% 5 14.3%
Isoechoic 25 71.4% 24 68.6%
Hyperechoic 5 14.3% 6 17.1%
Total 35 100% 35 100%

Based on the above distribution, we

obtained Hypoechoic renal parenchyma in
the right and left kidneys (14.3%), Isoechoic
renal parenchyma in the right kidney
(71.4%), left kidney (68.6%) and
Hyperechoic renal parenchyma in the right
kidney (14 .3%) while in the left kidney
(17.1%).
Next, based on these results, they
were classified into (2) groupsthe
Hypoechonic group and the
isoechoic/Hyperechoic group against the
reference and cross-tabulation was carried
out against the AKI/Non-AKI Classification
group and the Persistent/Transient AKI
Classification group so that it can be seen in
Table 7. Contingency of Echogenicity of Renal Parenchyma
Parenchymal Echogenicity Parenchymal Echogenicity
Right Kidney Left Kidney
Category
Hypoechoic Isoechoic/ Hypoechoic Isoechoic/
Hyperechoic Hyperechoic
Non-AKI (n=5) 0 (0%) 5 (14.3%) 0 (0%) 5 (14.3%)
AKI (n= 30) 5 (14.3%) 25 (71.4%) 5 (14.3%) 25 (71.4%)
Transient AKI (n=9) 3 (10%) 6 (20%) 3 (10%) 6 (20%)
Persistent AKI (n= 21) 2 (6.7%) 19 (63.3%) 2 (6.7%) 19 (63.3%)
 Of the 35 research samples, 30 patients
were found with AKI, where according to the
Spearmann test results in the Classification of
Persistent/Transient AKI Types, there was a
significant relationship with the echogenicity
classification variable of the right and left
kidney parenchyma (p=0.029, correlation
coefficient 0.398).

Correlation Characteristics and Risk Factors

in Cases of Persistent/Transient AKI with
Obstructive Uropathy Feature Variables.

Of the 35 research samples, observations were

made for the presence of obstructive features on
ultrasound of kidney morphology, and can be
seen in table 8 below:

Table 8 Distribution of variables describing

renal obstructive uropathy
Features of Right Left Kidney
Obstructive Kidney
Uropathy n % n %
There isn't 32 91.4% 33 94.3%
any
There is 3 8.6% 2 5.7%
Total 35 100 35 100

Based on the distribution, there was no

appearance of obstructive uropathy in the
right kidney (91.4%), while in the left
kidney it was (94.3%). Obstructive
uropathy was found in the right kidney
(8.6%) while in the left kidney it was
(5.7%).
Next based on these resultsA cross
tabulation was carried out on the AKI/Non
AKI Classification group and on the
Persistent/Transient AKI Classification
group so that it can be seen in table 9
below.
Table 9. Morphological Ultrasound Contingency Features of Renal Obstructive Uropathy
Overview of Obstructive Overview of Obstructive
Category UropathyRight Kidney UropathyLeft Kidney
There isn't any There is There isn't any There is
Non-AKI (n=5) 3 (8.6%) 2 (5.7%) 4 (11.4%) 1 (2.9%)
AKI (n= 30) 29 (82.9%) 1 (2.9%) 29 (82.9%) 1 (2.9%)
Transient AKI (n=9) 9 (30%) 0 (0%) 9 (30%) 0 (0%)
Persistent AKI (n= 21) 20 (66.7%) 1 (3.3%) 20 (66.7%) 1 (3.3%)

Based on the Spearmann correlation test,
it appears that there is a significant
influence between the classification of
AKI/Non AKI on the variable of the
absence of features of obstructive
uropathy in the right kidney (p=0.007,
a=0.005), but in the left kidney no
significant influence was found (p=0.137,
a- 0.05%).
Meanwhile, in the
Persistent/Transient AKI classification, no
significant influence was found on the
obstructive picture variable in both the
right and left kidneys (p=0.506, a=0.05).

DISCUSSION 42.43, Liu et all stated that this will manifest

In this study, an ultrasound examination to
determine the morphological profile of the
kidneys in cases of persistent/transient
AKI in pediatric patients was carried out
when there was a surge in cases of the
COVID pandemic in 2022, at which time
there was also a phenomenon of a spike in
the incidence of pediatric AKI. Although
there is still no research related to the
incidence of AKI with suspected
inflammatory syndrome in children (MIS-
C), the relationship and influence of the
morphological profile of kidney
ultrasound examination in cases of AKI
for the persistent/transient type of AKI
can be explained in this study.
in an increase in kidney size both in kidney
length and volume. kidneys and thickness of
renal parenchyma 8.
Moses and Fernandes stated that the
thickness of the kidney parenchyma can be a
differentiator between AKI and Chronic
Kidney Disease (CKD), where in CKD the
kidney parenchyma will gradually become
narrower along with a decrease in glomerular
filtration rate. 26. In contrast to the situation
with AKI where parenchymal thickness is
found to increase especially in AKI with
intrinsic etiology, but it should also be noted
that tissue damage due to AKI can be
irreversible which at a certain point will lead
to CKD in the future 11,44.

Correlation Analysis and Risk Factors

for Persistent AKI/Transient AKI
Classification on Length Classification
Variables,Classification of Kidney
Volume and Thickness of Kidney
Parenchyma.
The results showed a significant
correlation between the type of
persistent/transient AKI and changes in
kidney length. SThis is in line with the
pathological process that occurs in the
process of intra-renal AKI, namely the
occurrence of dilatation of the tubular lumen
and inflammatory edema in the intercellular
spaces in the renal parenchyma. The structure
of the intercellular tissue in the tubules and
glomeruli will thicken and edema in the
Injury phase will further be replaced by
fibro-necrosis tissue in the necrosis phase
Correlation Characteristics and Risk
Factors in Cases of Persistent/Transient
AKI on the Kidney Parenchymal
Echogenicity Classification Variable.
The results of the study showed that
there was a significant correlation between
the type of persistent/transient AKI and the
echogenicity of the kidney parenchyma.In
Kelahan's opinion, the kidney parenchyma
has begun to show changes to become
hypoechoic since the age of 6 months when
compared with the liver or spleen
parenchyma31, so the Isoechoic parenchyma
observed in the observations of this study (no
samples aged under 1 year) has been
included in the renal parenchyma echo
classification. which increases along with the
renal parenchyma which appears
hyperechoic. persistent/transient AKI type
The occurrence of changes in the renal calcification with the highest
parenchyma is related to the processes of frequency being Isoechogenic
Acute Tubular Injury and Acute Tubular echogenicity;
Necrosis and Interstitial Nephritis, which 5. Kidney ultrasound morphology
pathological processes underlie changes in examination on the variable picture of
the echogenicity of the renal parenchyma in renal obstructive uropathy did not
AKI with Intrinsic Renal etiology 8,42,46. have a significant correlation with the
type of persistent/transient AKI.
Furthermore, the author proposes that it is
Correlation Characteristics and Risk necessary to carry out further studies on
Factors in Cases of Persistent/Transient Resistive Index examinations in AKI
AKI with Obstructive Uropathy severity groups with research samples that
Feature Variables. can represent the population, and the need
The results of the study showed that to evaluate kidney volume calculations
there was a significant correlation between and routine measurements of renal
the type of persistent/transient AKI and the parenchymal thickness during Kidney
appearance of obstructive uropathy. Ultrasound examinations to increase the
BIdentification of features of obstructive contribution of Kidney Ultrasound
uropathy is more aimed at detecting the examination expertise for clinicians. in
presence of post-renal etiology, especially related scientific disciplines.
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