AC Portal
Variant: 1   Microhematuria. No risk factors, or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢
US kidneys and bladder retroperitoneal Usually Not Appropriate O
Arteriography kidney Usually Not Appropriate ☢☢☢
Radiography abdomen and pelvis Usually Not Appropriate ☢☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
MRU without and with IV contrast Usually Not Appropriate O
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTU without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 2   Microhematuria. Patients with risk factors, without any of the following: history of recent vigorous exercise, or presence of infection or viral illness, or present or recent menstruation, or renal parenchymal disease. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
CTU without and with IV contrast Usually Appropriate ☢☢☢☢
US kidneys and bladder retroperitoneal May Be Appropriate O
MRU without and with IV contrast May Be Appropriate O
CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast May Be Appropriate ☢☢☢☢
Arteriography kidney Usually Not Appropriate ☢☢☢
Radiography abdomen and pelvis Usually Not Appropriate ☢☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢

Variant: 3   Microhematuria. Pregnant patient. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US kidneys and bladder retroperitoneal Usually Appropriate O
MRU without IV contrast May Be Appropriate O
Arteriography kidney Usually Not Appropriate ☢☢☢
Radiography abdomen and pelvis Usually Not Appropriate ☢☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
MRU without and with IV contrast Usually Not Appropriate O
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTU without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 4   Gross hematuria. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRU without and with IV contrast Usually Appropriate O
CTU without and with IV contrast Usually Appropriate ☢☢☢☢
US kidneys and bladder retroperitoneal May Be Appropriate O
MRI abdomen and pelvis without and with IV contrast May Be Appropriate O
MRI abdomen and pelvis without IV contrast May Be Appropriate O
CT abdomen and pelvis with IV contrast May Be Appropriate ☢☢☢
CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast May Be Appropriate ☢☢☢☢
Arteriography kidney Usually Not Appropriate ☢☢☢
Radiography abdomen and pelvis Usually Not Appropriate ☢☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢

Panel Members
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Discussion of Procedures by Variant
Variant 1: Microhematuria. No risk factors, or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation. Initial imaging.
Variant 1: Microhematuria. No risk factors, or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation. Initial imaging.
A. Arteriography Kidney
Variant 1: Microhematuria. No risk factors, or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation. Initial imaging.
B. CT Abdomen and Pelvis
Variant 1: Microhematuria. No risk factors, or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation. Initial imaging.
C. CTU
Variant 1: Microhematuria. No risk factors, or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation. Initial imaging.
D. MRU
Variant 1: Microhematuria. No risk factors, or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation. Initial imaging.
E. MRI Abdomen and Pelvis
Variant 1: Microhematuria. No risk factors, or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation. Initial imaging.
F. Radiography Abdomen and Pelvis
Variant 1: Microhematuria. No risk factors, or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation. Initial imaging.
G. Radiography Intravenous Urography
Variant 1: Microhematuria. No risk factors, or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation. Initial imaging.
H. US Kidneys and Bladder Retroperitoneal
Variant 2: Microhematuria. Patients with risk factors, without any of the following: history of recent vigorous exercise, or presence of infection or viral illness, or present or recent menstruation, or renal parenchymal disease. Initial imaging.
Variant 2: Microhematuria. Patients with risk factors, without any of the following: history of recent vigorous exercise, or presence of infection or viral illness, or present or recent menstruation, or renal parenchymal disease. Initial imaging.
A. Arteriography Kidney
Variant 2: Microhematuria. Patients with risk factors, without any of the following: history of recent vigorous exercise, or presence of infection or viral illness, or present or recent menstruation, or renal parenchymal disease. Initial imaging.
B. CT Abdomen and Pelvis
Variant 2: Microhematuria. Patients with risk factors, without any of the following: history of recent vigorous exercise, or presence of infection or viral illness, or present or recent menstruation, or renal parenchymal disease. Initial imaging.
C. CTU
Variant 2: Microhematuria. Patients with risk factors, without any of the following: history of recent vigorous exercise, or presence of infection or viral illness, or present or recent menstruation, or renal parenchymal disease. Initial imaging.
D. MRU
Variant 2: Microhematuria. Patients with risk factors, without any of the following: history of recent vigorous exercise, or presence of infection or viral illness, or present or recent menstruation, or renal parenchymal disease. Initial imaging.
E. MRI Abdomen and Pelvis
Variant 2: Microhematuria. Patients with risk factors, without any of the following: history of recent vigorous exercise, or presence of infection or viral illness, or present or recent menstruation, or renal parenchymal disease. Initial imaging.
F. Radiography Abdomen and Pelvis
Variant 2: Microhematuria. Patients with risk factors, without any of the following: history of recent vigorous exercise, or presence of infection or viral illness, or present or recent menstruation, or renal parenchymal disease. Initial imaging.
G. Radiography Intravenous Urography
Variant 2: Microhematuria. Patients with risk factors, without any of the following: history of recent vigorous exercise, or presence of infection or viral illness, or present or recent menstruation, or renal parenchymal disease. Initial imaging.
H. US Kidneys and Bladder Retroperitoneal
Variant 3: Microhematuria. Pregnant patient. Initial imaging.
Variant 3: Microhematuria. Pregnant patient. Initial imaging.
A. Arteriography Kidney
Variant 3: Microhematuria. Pregnant patient. Initial imaging.
B. CT Abdomen and Pelvis
Variant 3: Microhematuria. Pregnant patient. Initial imaging.
C. CTU
Variant 3: Microhematuria. Pregnant patient. Initial imaging.
D. MRU
Variant 3: Microhematuria. Pregnant patient. Initial imaging.
E. MRI Abdomen and Pelvis
Variant 3: Microhematuria. Pregnant patient. Initial imaging.
F. Radiography Abdomen and Pelvis
Variant 3: Microhematuria. Pregnant patient. Initial imaging.
G. Radiography Intravenous Urography
Variant 3: Microhematuria. Pregnant patient. Initial imaging.
H. US Kidneys and Bladder Retroperitoneal
Variant 4: Gross hematuria. Initial imaging.
Variant 4: Gross hematuria. Initial imaging.
A. Arteriography Kidney
Variant 4: Gross hematuria. Initial imaging.
B. CT Abdomen and Pelvis
Variant 4: Gross hematuria. Initial imaging.
C. CTU
Variant 4: Gross hematuria. Initial imaging.
D. MRU
Variant 4: Gross hematuria. Initial imaging.
E. MRI Abdomen and Pelvis
Variant 4: Gross hematuria. Initial imaging.
F. Radiography Abdomen and Pelvis
Variant 4: Gross hematuria. Initial imaging.
G. Radiography Intravenous Urography
Variant 4: Gross hematuria. Initial imaging.
H. US Kidneys and Bladder Retroperitoneal
Summary of Recommendations
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Safety Considerations in Pregnant Patients

Imaging of the pregnant patient can be challenging, particularly with respect to minimizing radiation exposure and risk. For further information and guidance, see the following ACR documents:

·        ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI)

·        ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation

·        ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound

·        ACR Manual on Contrast Media

·        ACR Manual on MR Safety

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
References
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.