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Renal

Scintigraphy
Materials for medical students
Helena Balon, MD
Wm. Beaumont Hospital
Royal Oak, Michigan
Charles University
3rd School of Medicine
Dept Nucl Med, Prague

Indications
Evaluation of:
Renal

perfusion and function


Obstruction (Lasix renal scan)
Renovascular HTN (Captopril renal scan)
Infection (renal morphology scan)
Pre-surgical quantitation (nephrectomy)
Renal transplant
Congenital anomalies, masses
(renal morphology scan)

Renal Function
Blood

flow - 20% cardiac output to kidneys

(1200 ml/min blood, 600 ml/min plasma)


Filtration

- 20% renal plasma flow filtered by

glomeruli (120 ml/min, 170 L/d)


Tubular

secretion

Tubular

reabsorption (1% ultrafiltrate - urine)

Endocrine

functions

Renal Radiotracers

Excretion Mechanisms
GF
Tc-99m DTPA
Tc-99m MAG3
I-131 OIH
Tc-99m GHA
Tc-99m DMSA

TS

>95%
<5%
95%
20%
80%
40%-60%
some

TF

20%
60%
Semin NM Apr.92

Renal
Radiopharmaceuticals
Extract. fraction
Tc-99m DTPA
Tc-99m MAG3
I-131 OIH

20%
40-50%
~100%

Clearance
100-120 ml/min
~ 300 ml/min
500-600 ml/min

Renal Radiopharmaceuticals

Dosimetry
DTPA MAG3
mCi

rad/5mCi

Kidney
Bladder
EDE (rem)

0.2
2.8
0.3

GHA

DMSA

I-131OIH

rad/300Ci

0.15
5.1
0.4

1.6
2.7
0.4

3.5 0.01
0.3 0.3
0.3 0.03

rad/10

Choosing Renal
Radiotracers
Clin. Question
Perfusion
Morphology
Obstruction
Relative function
GFR quantitation
ERPF quantitation

Agent
MAG3, DTPA, GHA
DMSA, GHA
MAG3, DTPA, OIH
All
I-125 iothalamate,
Cr-51 EDTA, DTPA
MAG3, OIH

Basic Renal Scan

Procedure

Basic Renal Scintigraphy

Patient Preparation
Patient

must be well hydrated

Give 5-10 ml/kg water (2-4 cups)


30-60 min. pre-injection
Can measure U - specific gravity (<1.015)
Void

before injection
Void @ end of study
Intl Consens. Comm.
Semin NM 99:146-159

Basic Renal Scintigraphy

Acquisition
Supine
Do

position preferred

not inject by straight stick

Flow

(angiogram) : 2-3 sec / fr x 1 min

Dynamic:

15-30 sec / frame x 20-30 min


(display @ 1-3 min/frame)

Basic Renal Scintigraphy

Acquisition (contd)
Obtain

a 30-60 sec. image over injection site


@ end of study
if infiltration >0.5% dose
clearance

do not report

Obtain

post-void supine image of kidneys


@ end of study
Taylor, SeminNM 4/99:102-127

International Consensus
Committee Recommendations for
Basic Renogram

Tracer: MAG3, (DTPA)


Dose: 2 - 5 mCi adult, minimum 0.5 mCi peds

Pt. position: supine (motion, depth issues)


Include bladder, heart

Collimator: LEAP

Image over injection site


Intl Consens. Comm.
Semin NM 99:146-159

DTPA normal

DTPA normal

Relative (split) function


ROIs

Relative uptake
Contribution

% Lt kid =

of each kidney to the total fct

net cts in Lt ROI


--------------------------------------- x 100%
net cts Lt + net cts Rt ROI

Normal
Borderline
Abnormal

50/50 - 56/44
57/43 - 59/41
> 60/40
Taylor, SeminNM Apr 99

Basic Renal Scintigraphy

Processing
Time

to peak

Best from cortical ROI


Normal < 5 min
Residual

Cortical Activity (RCA20 or 30)

Ratio of cts @ 20 or 30 min / peak cts


Use cortical ROI
Normal RCA20 for MAG3 < 0.3
Residual

Urine Volume

(post-void cts x void. vol) (pre-void cts - post void cts)

DTPA flow + scan

GFR = 29 ml/
Creat = 2.0
L= 33%
R= 67%

Renal artery occlusion

Rt renal infarct

Renogram Phases
I.

Vascular phase (flow study): Ao-to-Kid ~ 3

II.

Parenchymal phase (kidney-to-bkg): Tpeak < 5

III.

Washout (excretory) phase

Renogram curves

Evaluation of
Hydronephrosis
Diuretic (Lasix) Renal Scan

Obstruction
Obstruction to urine outflow leads to
obstructive uropathy
(hydronephrosis, hydroureter)
and
may lead to obstructive nephropathy
(loss of renal function)

Diuretic Renal Scan

Principle
Hydronephrosis

- tracer pooling in dilated

renal pelvis
Lasix

induces increased urine flow

If

obstructed >>> will not wash out

If

dilated, non-obstructed >>> will wash out

Can

quantitate rate of washout (T 1/2)

Diuretic Renal Scan

Indications
Evaluate

functional significance of
hydronephrosis

Determine

need for surgery

obstructive hydronephrosis - surgical Rx


non-obstructive hydronephrosis - medical Rx
Monitor

effect of therapy

Diuretic Renal Scan

Requirements
Rapidly
Well

cleared tracer

hydrated patient

Good

renal function

Diuretic Renal Scan

Procedure
Pt.

preparation:
prehydration
adults - oral or 360ml/m2 iv over 30
peds - 10-15 ml/kg D5 0.3-0.45%NS

void before injection


bladder catheterization ?

Diuretic Renal Scan

Procedure (contd)
Tracers:

Tc-99m MAG3 5-10 mCi


(preferred over DTPA)

Acquisition:

supine until pelvis full


(can switch to sitting post- Lasix)

Flow

(angiogram) : 2-3 sec / fr x 1 min

Dynamic:

15-30 sec / frame x 20-30 min

Diuretic Renal Scan

Procedure (contd)

Void before Lasix

Lasix:

Acquisition for 30 min post Lasix

Assess adequacy of diuresis

40mg adult, 1mg/kg child iv


@ ~10-20 min (when pelvis full)
or @ -15min (F-15 method)

Measure voided volume


Adults produce ~200-300 ml urine post-Lasix

Diuretic Renal Scan

Procedure (contd)
Dont

give Lasix if

Collecting system still filling


Collecting system not full by 60 min
Collecting system drains spontaneously
Poor ipsilateral fct (< 20%)

pre-Lasix

post-Lasix

No UPJ obstruction

T1/2
R = 6
L = 2

Post-Lasix curve

Pre-Lasix

10 y/o M

Post-Lasix

Rt UPJ obstruction

T1/2
R = N/A

F/U - nephrostomy tube placed

Lt hydronephrosis

3-wk old baby

3164897

Lt UPJ obstruction

3164897

Rt UPJ obstruction

T1/2
R = N/A

F/U - nephrostomy tube placed

Lt UPJ obstruction

3164897

Diuretic Renal Scan

Processing
ROI

placement

around whole kidney or


around dilated renal collecting system
T/A curve
T1/2

from Lasix injection vs. from diuretic response


linear vs. exponential fit of washout curve

Diuretic Renal Scan

Washout
(diuretic response)
T1/2
time required for 50% tracer to leave
the dilated unit
i.e. time required for activity to fall
to 50% of peak

T1/2 washout
cts
100%

50%

T1/2

min

T1/2 value
Variables

influencing T1/2 value:

Tracer
State of hydration
Volume of dilated pelvis
Bladder catheterization
Dose of Lasix
Renal function (response to Lasix)
ROI (kidney vs. pelvis)
T1/2 calculation (from inj. vs. response, curve fit)

T1/2
Normal

< 10 min
Obstructed > 20 min
Indeterminate
10 - 20 min
Best

to obtain own normals for each


institution, depending on protocol used

Diuretic Renal Scan

Interpretation
Interpret
Visual

(dynamic images)

Washout

T1/2

whole study, not T1/2 alone


curve shape (concave vs. convex)

Diuretic Renal Scan

Pitfalls
False

positive for obstruction

Distended bladder
Gross hydronephrosis
T(transit time) = V (volume) F (flow)

Poorly functioning / immature kidney


Dehydration
False

negative

Low grade obstruction


Poorly functioning / immature kidney

Effect of catheterization (1)

full bladder,
no catheter

Effect of catheterization (2)

with catheter
in bladder

Effect of catheterization (3)

without catheter

with catheter

F minus 15
Diuretic Renogram
Furosemide

(Lasix) injected 15 min before


radiopharmaceutical

Rationale:

kidney in maximal diuresis,


under maximal stress

Some

equivocals will become clearly


positive, some clearly negative
English, Br JUrol 1987:10-14
Upsdell, Br JUrol 1992:126-132

Evaluation of
Renovascular
Hypertension
Captopril Renal Scan
(ACEI Renography)

Renovascular Disease
Renal

artery stenosis (RAS)

Ischemic

nephropathy

Renovascular

RAS RVH

hypertension (RVH)

Renovascular
Hypertension
Caused

by renal hypoperfusion

Atherosclerosis
Fibromuscular dysplasia
Mediated

by renin - AT - aldosterone system

Potentially

curable by renal revascularization

Renovascular
Hypertension
Prevalence

<1% unselected population with HTN


Clinical

features

Abrupt onset HTN in child, adult < 30 or > 50y


Severe HTN resistant to medical Rx
Unexplained or post-ACEI impairment in ren fct
HTN + abdominal bruits
If these present - moderate risk of RVH (20-30%)

Renin-Angiotensin System
Angiotensinogen

RAS
Renin

Angiotensin I

Captopril

ACE

Angiotensin II
Aldosterone

Vasoconstriction

HTN

Effect of RAS on GFR

Diagnosis of RAS
Gold

std: angiography

Initial

non-invasive tests:

ACEI renography
Duplex sonography
Other

tests:

MRA - insensitive for distal / segmental RAS


Captopril test (PRA post-C.) - low sensitivity
Renal vein renin levels

ACEI Renography

ACEI Renography

Patient Preparation

Off ACEI & ATII receptor blockers x 3-7 days

Off diuretics x 5-7d

No solid food x 4 hrs

Patient well hydrated


10 ml/kg water 30-60 min pre- and during test

ACEI
Captopril 25-50 mg po (crushed), 1 hr pre-scan
Enalaprilat 40 g/kg iv (2.5 mg max), 15 min pre-scan
Monitor BP q 15 min

ACEI Renography

Procedure
Tracer:

Tc-99m MAG3 (or DTPA)

Protocol:

1 day vs. 2 day test

1 day test: baseline scan (1-2 mCi) followed by


post-Capto scan (8-10
mCi)
2 day test: post-Capto scan,
only if abnormal >> baseline
Acquisition:

flow & dynamic x 20-30 min.

ACEI Renography

Processing
Relative
Time

renal uptake (bkg corrected)

to peak (Tp) - from cortical ROI

normal < 5 min


RCA20

(20 min/peak ratio) - from cortical ROI

normal < 0.3

ACEI Renography

Grading renogram curves

ACEI Renography

Diagnostic Criteria
MAG3:

ipsilateral parenchymal retention

p.C.
change in renogram curve by 1 grade
RCA20 increase by 15% (e.g. from 30% to 45%)
Tp increase by 2 min or 40% (e.g. from 5 to 7)

DTPA:

ipsilateral decreased uptake

Decrease in relative uptake 10%


(e.g.from 50/50 to 40/60), change of 5-9% - intermediate
change in renogram curve by 2 grades
Consens. report JNM 96:1876
Semin NM 4/99:128-145

ACEI Renography

Interpretation
High

probability RVH (>90%)

Marked C-induced change


Low

probability RVH (<10%)

Normal Captopril scan


Abnormal baseline, improved p-C.
Type I curve - pre- and post-C.
Intermediate

probability RVH

Abnl baseline, no change p-C.

Captopril Renal Scan


MAG 3

Captopril Renal Scan MAG3

Captopril Renal Scan


MAG 3

Captopril Renal Scan


MAG 3

ACEI Renography
In

normal renal function - sens/spec ~ 90%


In poor renal fct / ischemic nephropathy,
ACEI renography often indeterminate
>>> do MRA, Duplex US, angio

Evaluation of Renal
Infection
Renal Morphology Scan
(Renal Cortical
Scintigraphy)

UTI
VUR

risk factor for PN,


not all pts w PN have VUR
PN

may lead to scarring >>> ESRD, HTN

early Dx and Rx necessary


Clinical

& laboratory Dx of renal involvement


in UTI unreliable

Renal Cortical Scintigraphy

Indications
Determine

involvement of upper tract

(kidney) in acute UTI (acute pyelonephritis)


Detect

cortical scarring (chronic pyelonephr.)

Follow-up

post Rx

Renal Cortical Scintigraphy

Procedure
Tracers

Tc-99m DMSA
Tc-99m GHA
Acquisition

2-4 hrs post-injection


parallel hole posterior
pinhole post. + post. oblique (or SPECT)
Processing:

relative fct

Renal Cortical Scintigraphy

Interpretation
Acute

PN

single or multiple cold defects


renal contour not distorted
diffuse decreased uptake
diffusely enlarged kidney or focal bulging
Chronic

PN

volume loss, cortical thinning


defects with sharp edges
Differentiation

of AcPN vs. ChPN unreliable

Renal Cortical Scintigraphy

Cold Defect
Acute

or chronic PN
Hydronephrosis
Cyst
Tumors
Trauma (contusion, laceration, rupture,
hematoma)
Infarct

DMSA
parallel hole collimator

Normal DMSA
pinhole

LPO

RPO

DMSA

Acute pyelonephritis
DMSA
post L

post R

LEAP
LPO

pinhole

RPO

Renal Cortical Scintigraphy

Congenital Anomalies
Agenesis
Ectopy
Fusion (horseshoe, crossed fused ectopia)
Polycystic

kidney

Multicystic

dysplastic kidney

Pseudomasses (fetal lobulation, hypertrophic

column of Bertin)

DMSA
horseshoe kidney

parallel

pinhole

DMSA
Lt Agenesis

parallel

GHA
Crossed ectopia

74%

26%

Radionuclide
Cystogram

Indications
Evaluation

of children with recurrent UTI

30-50% have VUR


F/U

after initial VCUG

Assess

effect of therapy / surgery

Screening

of siblings of reflux pts.

Methods
Direct

Tc-99m S.C. or TcO4

via Foley

Advant.
can do at any age
VUR during filling
Disadv.
catheterization

Indirect
Tc-99m DTPA or
Tc-99m MAG3
i.v.

no catheter
info on kidneys

need pt
cooperation
need good renal
fct

Direct Cystography
1

mCi S.C. in saline via Foley


Fill bladder until reversal of flow
(bladder capacity = (age+2) x 30
Continuous

imaging during filling & voiding


Post void image
Record
volume instilled
volume voided
pre- and post- void cts

RN Cystogram vs.
VCUG
Advantages
Lower radiation dose
(5 vs 300 mrad to
ovary)
Smaller amount of
reflux detectable
Quantitation of postvoid residual volume

Disadvantages
Cannot detect distal
ureteral reflux
No anatomic detail
Grading difficult

Normal cystogram

filling

voiding

post-void

VUR - filling phase

VUR - voiding phase &


post-void

Post void residual


volume

RV =

voided vol x post-void cts


pre-void cts - post void cts

Reflux nephropathy
16%

84%