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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

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RENAL RADIONUCLIDE STUDIES Kateřina Michalová

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Renal radionuclide studies kate ina michalov

RENAL

RADIONUCLIDE STUDIES

Kateřina Michalová


Renal radionuclide studies kate ina michalov

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


Renal radionuclide studies kate ina michalov

  • Nuclear renal imaging

  • includes these methods

  • Renal dynamic scintigraphy

  • Renal cortical scintigraphy

  • Radionuclide Cystography


Renal radionuclide studies kate ina michalov

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.


Renal radionuclide studies kate ina michalov

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

RadiopharmaceuticalsMechanisms of excretionyou can see in the picture

Glomerular filtration

  • 99mTc DTPA

    Tubular secretion

  • 99mTc MAG3

  • 131I, 123I – OIH

    Tubular fixation

  • 99mTc DMSA

  • 99mTc glucoheptonate


Renal radionuclide studies kate ina michalov

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.


Renal radionuclide studies kate ina michalov

  • 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


Renal radionuclide studies kate ina michalov

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


Renal radionuclide studies kate ina michalov

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 startsimmediatelly 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


Renal radionuclide studies kate ina michalov

  • Evaluation

  • visuel

  • parenchymal phase

  • position

  • size

  • shape

  • distribution RF

  • excretory phase

  • dilatation of the collecting system


Renal radionuclide studies kate ina michalov

Computer processing of the study

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


Renal radionuclide studies kate ina michalov

Computer processing of the study

Renogram curves

Parameters of the curves

Time activity curves derived from renal ROI

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


Renal radionuclide studies kate ina michalov

Computer processing of the study

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

Normal renogram curve

I. Vascular phase II. Secretory

III. Excretory

A

II.

III.

I.

čas


Renal radionuclide studies kate ina michalov

Patterns of renographic curves

A

obstructed pattern

impaired renal function

parenchymal lesion pattern

renal failure patern

normal

renal failure pattern

without measurable kidney uptake

čas


Renal radionuclide studies kate ina michalov

Dynamic renal study

Indications

All uropaties, which require evaluation of individual renal function at diagnosis and during the different phases ofsurgical 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.


Renal radionuclide studies kate ina michalov

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


Renal radionuclide studies kate ina michalov

A

obstruction

no response to a diuretic

no washout of RP from

the collecting system

non obstruction

dilatation

(hypotonie

stasis)

rapid washout from

the collecting system

Furosemid i.v.

čas


Renal radionuclide studies kate ina michalov

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


Renal radionuclide studies kate ina michalov

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

vertical

position

furosemid

non obstruction

dilatation

(hypotonie

stasis)

rapid washout from

the collecting system

no obstruction


Renal radionuclide studies kate ina michalov

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

vertical

position

furosemid

obstruction

poor response to a diuretic

no washout of RP from

the collecting system


Renal radionuclide studies kate ina michalov

Right kidney

-enlarged

hypofunctional

impresion

of dilatated

collecting is

seen, but no

good fiiling

no response

to a diuretic

Left kidney

normal

obstruction

no response to a diuretic

severe obstruction

no response to a diuretic

no washout of RP from

the collecting system


Renal radionuclide studies kate ina michalov

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 radionuclide studies kate ina michalov

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 !!!)


Renal radionuclide studies kate ina michalov

  • Renal cortical scintigraphy

  • Common Indications

  • Acute pyelonephritis

  • Renal scarring

  • Relativ functioning renal mass

  • Solitary or ectopic renal tissue (e.g.,pelvic kidney)

  • Horseshoe and pseudohorseshoe kidneys

  • Allergie to iodinated contrast agents

  • Society of Nuclear Medicine Procedure Guideline for Renal Cortical Scintigraphy in Children


Renal radionuclide studies kate ina michalov

Renal cortical scintigraphy

- 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


Renal radionuclide studies kate ina michalov

Normal renal scan

ANT POST

RPO LPO


Renal radionuclide studies kate ina michalov

  • 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


Renal radionuclide studies kate ina michalov

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%


Renal radionuclide studies kate ina michalov

Acute pyelonephritis

(multifocal)

-more foci of reduced accumulation

of the RP

-diffuse damage to the parenchyma


Renal radionuclide studies kate ina michalov

Scarring

characterized as :

-wedshaped defects

-with thinning

or flattening

of the cortex

-irregular

margins

-loss of volume

of the kidney

ANT POST

RPO LPO

2-years old girl after repeated infection of uropoetic system


Renal radionuclide studies kate ina michalov

Anomalies of position and number

dystopia

ANT POST


Renal radionuclide studies kate ina michalov

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.

Radiopharmaceutical99mTc- MAG3

Patient preparation no

Time of examination 1 h


Renal radionuclide studies kate ina michalov

  • Direct Radionuclide Cystography

  • Common Indication

  • Screening and therapy monitoring vesicoureteral

  • reflux

  • Diagnostic offamiliar 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 sensitivityfor detectionof vesicoureteral reflux

  • does not provide the same anatomic details as X-ray MCG

  • Society of Nuclear Medicine Procedure Guideline for Radionuclide Cystography in Children


Renal radionuclide studies kate ina michalov

Direct Radionuclide Cystography

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


Renal radionuclide studies kate ina michalov

Visual evaluation

Normal pattern

no activity is recorded in the ureters


Renal radionuclide studies kate ina michalov

VUR grade I(into ureter)


Renal radionuclide studies kate ina michalov

VUR grade II(into collecting system of the kidney)


Renal radionuclide studies kate ina michalov

VUR grade III(into collecting system of the kidney

with a dilatation)


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