This document discusses the use of radio-nuclides in nephro-urology. It describes various radiotracers including Tc99m DTPA and Tc99m MAG3 that are commonly used for renal scintigraphy to evaluate renal function and obstruction. Specific indications and interpretations for renal perfusion scans, Lasix renal scans, renal transplant scans, and DMSA scans are provided. The basic principles of acquiring and interpreting renograms are also summarized.

1. Radio-nuclidesRadio-nuclides
inin
Nephro-urologyNephro-urology
Essam Abou-Bieh, MD
Urology & Nephrology Center
Mansoura University

2. Tc99m
short half-life 6hs
emitted photon has an appropriate energy
metastable
molybdenum

3. molybdenum

4. Scintigraphic Renal Studies
Indications
• Renal perfusion
• Renal function
• Renal outflow obstruction (Lasix renal scan)
• Reno vascular HTN (Captopril renal scan)
• Congenital anomalies
• Renal parenchymal lesions (renal morphology scan)
• Renal transplant

5. Radio-nuclides in Nephro-urology
either:
Dynamic: for functional evaluation
Static: for anatomical assessment as pyelonephritis or ischemia
Renal Radiopharmaceuticals:
Tracers for Dynamic Studies:
 Tc-99m DTPA (diethylene-triamine-pentaacetate) Cleared by
glomerular filtration
 Tc-99m MAG3 (mercaptoacetyltriglycine) Cleared by tubular
secretion
Tracers for Static Studies:
Cleared by tubular secretion, retained in the renal cortex and minimally
excreted in urine
 Tc-99m DMSA (dimercaptosuccinic acid).

6. Tc-99m DTPA Tc-99m MAG-3

7. Tc-99m DTPA
Diethylenetriamine pentaceticacid (3-5 mCi)
Excretion: glomerular filtration
Indications
•Assessment of renal perfusion, function (GFR), and
renal/ureteralobstruction
•Less desirable for renal cortical detail or renal size

8. Tc-99m MAG-3
Mercapto-acetyl-triglycine (3-5 mCi)
Indications
Renal perfusion, function (ERPF -not a direct
measurement, but provides a reasonable
approximation)

9. Basic Renal Scintigraphy
Patient Preparation
Patient must be well hydrated 30-60 min. pre-injection
Void before injection

10. Image Acquisition and Interpretation

13. Renogram Phases
I. Vascular (perfusion) phase: Kid-to-Ao
II. Uptake phase
III. Excretory (washout ) phase

17. Acute & chronic renal failure
differentiation
Acute renal failure
More or less preserved perfusion
Mild reduction in tracer uptake
Some delay in excretion due to parenchymal retension of the
tracer
Chronic renal failure
Small kidney
Marked reduction in perfusion & tracer uptake
Excretion usually not affected.

18. CRF

19. DTPADTPA
GFR = 25 ml/’
Creat = 3.0
L= 33%
R= 67%
CRF

20. Evaluation of
Hydronephrosis
Diuretic (Lasix) Renal Scan

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

22. Diuretic Renal Scan
Principle
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 (T1/2)

23. 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

26. 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.

27. T1/2
Normal < 10 min
Obstructed > 20 min
Indeterminate 10 - 20 min
Best to obtain own normals for each institution,
depending on protocol used

28. Diuretic Renal Scan Interpretation
Interpret whole study, not T1/2 alone
Visual (dynamic images)
Washout curve shape
 T1/2

29. “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

30. Renovascular Hypertension
Caused by renal hypoperfusion
Atherosclerosis
Fibromuscular dysplasia
Mediated by renin - AT - aldosterone system
Potentially curable by renal revascularization
Captopril Renal Scan (ACEI Renography)
Evaluation of Renovascular Hypertension

31. Off ACEI & ATII receptor blockers x 3-7 days
Off diuretics for 5-7d
No solid food for 4 hrs
Patient well hydrated
ACEI
Captopril 25-50 mg po (crushed), 1 hr pre-scan
ACEI RenographyACEI Renography
Patient PreparationPatient Preparation

33. Basal
Captopril

41. Renal Transplant
Assessment of the donor.
Assessment of the recipient.
Acute rejection vs ATN.
Vascular : arterial/venous occlusion.
Urological: obstruction, leakage.
DD of urinoma from other collection.
Chronic complications:
Chronic rejection,
Ureteric stricture,
etc……………

42. Donor.

43. Donor.

44. Normal graft

45. Normal graft

46. Tc-99m DTPA
Urinoma.

47. ATN

48. ATN

49. FK toxicity

50. FK toxicity

51. Upper polar
infaraction

52. Tc-99m DMSA

53. “Cold Defect “
Acute or chronic PN
Hydronephrosis
Cyst
Tumors
Trauma (contusion, laceration, rupture,
hematoma)
Infarct
DD of true SOL from pseudo tumor

54. Renal Cortical Scintigraphy
Procedure
Tracers
Tc-99m DMSA (3-5 mCi)
Acquisition
2 hrs post-injection
Processing: relative uptake

55. Tc-99m DMSA
Dimercapto-succinic Acid (3-5 mCi)
Indications
•Tracer of choice for renal parenchymal evaluation
•Not suitable for perfusion or obstruction
•Limited function assessment, but can provide
differential renal function

56. 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 Ac PN vs. Ch PN unreliable

57. DMSA grading for chronic pyelonephritis
Grade 0 : Normal
Grade I : One lesion (or) reduced uptake (< 45%)
Grade II : One lesions + reduced uptake
Grade III : More than one lesion

58. Normal DMSA SCAN

59. Normal DMSA SCAN

60. Grade I pyelonephritic
changes of left kidney

61. Grade I pyelonephritic
changes of left kidney

62. - Grade II pyelonephritic left kidney.
- Normal DMSA scan right kidney.

63. - Grade II pyelonephritic left kidney.
- Normal DMSA scan right kidney.

64. Tc-99m DMSA
Ant. Post.
Grade III

65. post L
LPO pinhole
post R
RPO
LEAP

66. Tc-99m DMSA performed initially in this case with fever and Lt. loin pain.
Follow up scan conducted after one month.
Initial scan Follow up scan @ 1 m
Resolved focal nephritis.
Tc-99m DMSA

67. Renal Cortical Scintigraphy
Congenital Anomalies
Agenesis
Ectopy
Fusion (horseshoe, crossed fused ectopia)
Polycystic kidney
Multicystic dysplastic kidney
Pseudomasses (fetal lobulation, hypertrophic column
of Bertin)

70. Tc-99m DMSA
Ant. Post.
Ant.
Post.
Case 1
Case 2
Ectopic “pelvic” Lt. kidney.
Crossed fused ectopia.

71. Tc-99m DMSA
Polycystic kidneys

72. Bone Scan
Tc99m MDP
methyl diphosphonate

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