Renal Scans, Scintigraphy.pptx

Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
RENAL
RADIONUCLIDE STUDIES
Kateřina Michalová

Radionuclide diagnostics methods
Noninvasive
Are primarily physiologic
Functional
Does not provide the same anatomic details
as morphologic method (X-ray,US,CT,MRI)
Kupka K .a kol: Nukleární medicína, 2002

Nuclear renal imaging
includes these methods
1. Renal dynamic scintigraphy
2. Renal cortical scintigraphy
3. Radionuclide Cystography

Dynamic renal scintigraphy
Is a functional examination
Providing information about intrarenal kinetics
Of the i.v. applied radiopharmaceutical
And of its transport via the efferent urinary tracts
The specific information obtained depends of
radiopharmaceutic injected.

Dynamic renal scintigraphy
There are two kinds of
Radiopharmaceticals:
a) Tubular agents
99mTc-MAG3 Mercapto-acetyltriglycin
131I -,123I-Ortoiodhippurate
b) Glomerular filtration rate agens
99mTc-DTPA
Diethylentriamine pentaacetic acid

Radiopharmaceuticals
Mechanisms of excretion
you can see in the picture
Glomerular filtration
• 99mTc DTPA
•
Tubular secretion
• 99mTc MAG3
• 131I, 123I – OIH
Tubular fixation
• 99mTc DMSA
• 99mTc glucoheptonate

Radiopharmaceticals
99mTc-DTPA – Diethylentriamine pentaacetic acid
belongs to the group of chelate compounds
is excreted from kidneys through glomerular filtration
with a half-life of 70 minutes
it is the most suitable substance
for measuring glomerular filtration (GFR)
and good imaging of renal parenchyma
Vižďa J. a kol : Atlas of Renal Scintigraphy, 2002.

Radiopharmaceticals
99mTc-MAG3 - Mercapto-acetyltriglycine
-is one of the newly developed radiopharmaceuticals
-is rapidly excreted by the kidneys via active tubular secretion
and minor part via glomerular filtration
-organic anions (which include MAG3) have a carboxyl group which
specifically binds to the receptors of tubular cells mediating the
active transport of MAG3 into the cells of the proximal tubulus
-with normaI renal function 70% of the administered activity of the
radiopharmaceutical (RP) is excreted within 30 minutes after the
application

Dynamic renal study
Radiopharmaceutical
99mTc - MAG3
Patient Preparation
adequately hydration prior to the examination
it is recommended to drink 100 ml of liquids per 10 kg
of the body weight 30 min prior the examination
empty bladder
p.are requested to void completely prior to the study

Dynamic renal study
Image Acquisition
p.is usually examined in the supine position
sometimes in sitting position
detector of the gamma camera is in the posterior
projection
field of view includes the area of kidneys, ureters
and the area of the bladder
data recording starts immediatelly before the intravenous
injection
as serial 15 sec images for 20 min
radionuclide angiography
1 s frames are recorded for a period 1 minut after
the administration of the RF
can be used in examination of kidney grafts

Evaluation
• visuel
• parenchymal phase
• position
• size
• shape
• distribution RF
• excretory phase
• dilatation of the collecting system

Summed image of all frames during the clearance
phase
ROI (regions of interest) are drawn
Renal ROI – arround the kidney
Background ROI–below the kidney
Computer processing of the study

Renogram curves
Parameters of the curves
Tmax = time of
achieving the peak
of the curve
T1/2 = interval
between the time of
achieving the peak
of the curve
and the decrease
to 50% of the peak
level
Time activity curves derived from renal ROI

quantitation of the individual renal function
differential renal function DRF
calculated within 1 to 3 minutes
post injection of RP
physiological range is 45%-55%

Normal renogram curve
A
II. III.
I.
I. Vascular phase
II. Secretory
III. Excretory
čas

A
čas
normal
obstructed pattern
impaired renal function
parenchymal lesion pattern
renal failure pattern
without measurable kidney uptake
renal failure patern
Patterns of renographic curves

Dynamic renal study
Indications
All uropaties, which require evaluation of individual renal
function at diagnosis and during the different phases of
surgical or conservative treatment
and evaluation of the drainage function
Examples include dilatation of the cause (e.g.Pelvi-Ureteric and Vesico-
Ureteric dilatation), bladder dysfunction, complicated duplex kidney,
post trauma, asymetrical renal function and reflux nefropathy.

Diuretic Renography
The purpose of diuretic renography is to differentiate
a true obstruction from a dilated non obstructed system
(stasis) by serial imaging after intravenous administration
of furosemide (Lasix))
1) Standart renogram
When dilatation of the collecting system exists,
standart renogram should be complemented by a diuretic renogram
2) Diuretic renogram – additional 15-20 min acquisition, using
the same technique as above
Furosemid - 1mg/kg with a maximum dose 20mg (40 mg dle *SNM)
*Society of Nuclear Medicine Procedure Guadeline for Diuretic Renography in Children

A
čas
non obstruction
dilatation
(hypotonie
stasis)
rapid washout from
the collecting system
obstruction
no response to a diuretic
no washout of RP from
Furosemid i.v.

Diuretic renography
Indications
differentiation obstructive
from non obstructive causes
of hydronephrosis and hydroureteronephrosis
Ureteropelvic or ureterovesical obstruction
Prenatal ultrasound diagnosis of hydronephrosis
Post-surgical evaluation of the previously obstructed system
Distension of pelvicalyceal system as an etiology of back pain

no obstruction
non obstruction
dilatation
(hypotonie
stasis)
rapid washout from
furosemid
vertical
position
Left kidney
-enlarged
-dilated
collecting system
with pronounced
retention of urine
-response to
the diuretic is
rapid
Right kidney
normal shape
collecting system
with pronounced
retentin of urine
-response
to the diuretic
is rapid

obstruction
poor response to a diuretic
Left kidney
-enlarged
-dilated
collecting system
with pronounced
retention of urine
-poor response to
the diuretic
Right kidney
washout
of urine is free
by nefrostomy
furosemid
vertical
position

obstruction
Right kidney
-enlarged
hypofunctional
impresion
of dilatated
collecting is
seen, but no
good fiiling
no response
to a diuretic
Left kidney
normal
severe obstruction

Renal Cortical Scintigraphy
Static imaging of the kidney
Radiofarmaceutical : 99mTc-DMSA Dimercaptosuccinic
acid
Following iv injection is taken up into the renal cortex in the proximal
convoluted tubule.
The main site of accumulation are the microsomes of the cells of
proximal tubules.
It is cleared slowly , urine exrection is low.

Renal cortical scintigraphy
Patient Preparation no
Image Acquisition static high resolution images of kidneys
(ANT, POST, RPO, LPO projection)
SPECT
in the supine position
2,5 h after injection
DMSA cleared slowly (high radiation dose
versus DRS !!!)

Common Indications
1. Acute pyelonephritis
2. Renal scarring
3. Relativ functioning renal mass
4. Solitary or ectopic renal tissue (e.g.,pelvic kidney)
4. Horseshoe and pseudohorseshoe kidneys
5. Allergie to iodinated contrast agents
Society of Nuclear Medicine Procedure Guideline for Renal Cortical Scintigraphy in Children

- is used for detection of cortical defects of acute pyelonephritis (loss
of function) and scarring related to chronic pyelonephritis.
- is able to detect twice as many defects as ultrasound
4 times as many defects as intravenous urography
- computed tomography has sensitivity and specificity similar
but adds to the risk of contrast reaction and has a higher radiation
exposure
- magnetic resonance imaging is promising but expensive
nonionizing method of vizualizing pyelonephritis
Society of Nuclear Medicine Procedure Guideline for Renal Cortical Scintigraphy in Children

ANT POST
RPO LPO
Normal renal scan

Evaluation
- number of kidneys
- position
- size
- shape
- the size, number and location of areas cortical loss
- split renal function Note!
Cortical „cold“ defect may be due to
different etiology :
tumor, abscess, cysts ….
alrealdy is necesarry to compare with US

Evaluation of split renal function
- for determination of percent differential function regions of interest of each kidney and
background area are outlined on the computerized posterior and anterior images.
- split renal function normally varies from 45%-55%

Acute pyelonephritis
(multifocal)
-more foci of reduced accumulation
of the RP
-diffuse damage to the parenchyma

Scarring
2-years old girl after repeated infection of uropoetic system
ANT POST
RPO LPO
characterized as :
-wedshaped defects
-with thinning
or flattening
of the cortex
-irregular
margins
-loss of volume
of the kidney

ANT POST
dystopia
Anomalies of position and number

Direct Radionuclide Cystography
Micturating cystography (MCG)
-The examination is performed in the same way as X-ray MCG
-Requires catheterization of the bladder and instilation of
radionuclide and fluid for maximal physiological distension of
the bladder,
-Allowing imaging (dynamic scintigraphy) during filling, voiding,
and after voiding.
Radiopharmaceutical 99mTc- MAG3
Patient preparation no
Time of examination 1 h

Common Indication
Screening and therapy monitoring vesicoureteral
reflux
Diagnostic of familiar reflux
Evaluation of vesicoureteral reflux after medical management
Assesment of resuls of antireflux surgery
Comparing with conventional radiographic technique (X-
ray MCG)
• less gonadal radiation (100-200x lower than X-ray MCG)
• higher sensitivity for detection of vesicoureteral reflux
• does not provide the same anatomic details as X-ray MCG
Society of Nuclear Medicine Procedure Guideline for Radionuclide Cystography in Children

Vezikoureteral reflux
Interpretation criteria
Grade
I. with activity limited to the ureter
II. with activity reaching the collecting system
with none or minimal activity in ureter
III. with a dilatation of the collecting system
and dilated ureter
Society of Nuclear Medicine Procedure Guideline for Radionuclide Cystography in Children

Visual evaluation
Normal pattern
no activity is recorded in the ureters

VUR grade I (into ureter)

VUR grade II (into collecting system of the kidney)

VUR grade III (into collecting system of the kidney
with a dilatation)

Renal Scans, Scintigraphy.pptx

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