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Renal Scintigraphy PowerPoint PPT Presentation

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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. Renal perfusion and function Obstruction (Lasix renal scan) Renovascular HTN (Captopril renal scan) - PowerPoint PPT Presentation

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Renal Scintigraphy

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Renal scintigraphy l.jpg

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 l.jpg

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)


Evaluation of:

Renal function l.jpg

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 l.jpg

Renal RadiotracersExcretion Mechanisms

GF TS TFTc-99m DTPA>95%

Tc-99m MAG3<5%95%

I-131 OIH20%80%

Tc-99m GHA40%-60%20%

Tc-99m DMSAsome 60%

Semin NM Apr.92

Renal radiopharmaceuticals l.jpg

Renal Radiopharmaceuticals

Extract. fractionClearance

Tc-99m DTPA20% 100-120 ml/min

Tc-99m MAG340-50% ~ 300 ml/min

I-131 OIH~100% 500-600 ml/min

Renal radiopharmaceuticals dosimetry l.jpg

Renal RadiopharmaceuticalsDosimetry

DTPA MAG3 GHA DMSA I-131OIH rad/10 mCirad/5mCi rad/300µCi

Kidney0.2 0.151.6 3.50.01

Bladder2.85.1 2.7 0.30.3

EDE (rem) 0.3 0.40.4 0.30.03

Choosing renal radiotracers l.jpg

PerfusionMAG3, DTPA, GHA

MorphologyDMSA, GHA

Obstruction MAG3, DTPA, OIH

Relative functionAll

GFR quantitationI-125 iothalamate,


ERPF quantitationMAG3, OIH

Choosing Renal Radiotracers

Clin. QuestionAgent

Basic renal scan procedure l.jpg

Basic Renal ScanProcedure

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Basic Renal ScintigraphyPatientPreparation

  • 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

Int’l Consens. Comm.

Semin NM ‘99:146-159

Basic renal scintigraphy acquisition l.jpg

Basic Renal ScintigraphyAcquisition

  • Supine position preferred

  • Do 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 cont d l.jpg

Basic Renal ScintigraphyAcquisition (cont’d)

  • Obtain a 30-60 sec. image over injection site @ end of study

    • if infiltration >0.5% dose do not report clearance

  • Obtain post-void supine image of kidneys @ end of study

Taylor, SeminNM 4/99:102-127

International consensus committee recommendations for basic renogram l.jpg

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

Int’l Consens. Comm.

Semin NM ‘99:146-159

Dtpa normal l.jpg

DTPA normal

Dtpa normal14 l.jpg

DTPA normal

Relative split function roi s l.jpg

Relative (split) functionROI’s

Relative uptake l.jpg

Relative uptake

  • Contribution of each kidney to the total fct

    net cts in Lt ROI

    % Lt kid = --------------------------------------- x 100%

    net cts Lt + net cts Rt ROI

    • Normal50/50 - 56/44

    • Borderline57/43 - 59/41

    • Abnormal> 60/40

Taylor, SeminNM Apr 99

Basic renal scintigraphy processing l.jpg

Basic Renal ScintigraphyProcessing

  • 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)

Slide18 l.jpg

DTPA flow + scan

GFR = 29 ml/’

Creat = 2.0

L= 33%

R= 67%

Renal artery occlusion l.jpg

Renal artery occlusion

Rt renal infarct l.jpg

Rt renal infarct

Renogram phases l.jpg

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 l.jpg

Renogram curves

Evaluation of hydronephrosis l.jpg

Evaluation of Hydronephrosis

Diuretic (Lasix) Renal Scan

Obstruction l.jpg


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

Diuretic renal scan principle l.jpg

Diuretic Renal ScanPrinciple

  • 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 (T1/2)

Diuretic renal scan indications l.jpg

Diuretic Renal ScanIndications

  • 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 l.jpg

Diuretic Renal ScanRequirements

  • Rapidly cleared tracer

  • Well hydrated patient

  • Good renal function

Diuretic renal scan procedure l.jpg

Diuretic Renal ScanProcedure

  • 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 cont d l.jpg

Diuretic Renal ScanProcedure (cont’d)

  • 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 cont d30 l.jpg

Diuretic Renal ScanProcedure (cont’d)

  • Void before Lasix

  • Lasix: 40mg adult, 1mg/kg child iv@ ~10-20 min (when pelvis full)or @ -15min (“F-15” method)

  • Acquisition for 30 min post Lasix

  • Assess adequacy of diuresis

    • Measure voided volume

    • Adults produce ~200-300 ml urine post-Lasix

Diuretic renal scan procedure cont d31 l.jpg

Diuretic Renal ScanProcedure (cont’d)

  • Don’t give Lasix if

    • Collecting system still filling

    • Collecting system not full by 60 min

    • Collecting system drains spontaneously

    • Poor ipsilateral fct (< 20%)

Pre lasix l.jpg


Post lasix l.jpg


No upj obstruction l.jpg

No UPJ obstruction


R = 6’

L = 2’

Post lasix curve l.jpg

Post-Lasix curve

Pre lasix36 l.jpg


10 y/o M

Post lasix37 l.jpg


Rt upj obstruction l.jpg

Rt UPJ obstruction


R = N/A

F/U - nephrostomy tube placed

Slide39 l.jpg

Lt hydronephrosis

3-wk old baby


Slide40 l.jpg

Lt UPJ obstruction


Rt upj obstruction41 l.jpg

Rt UPJ obstruction


R = N/A

F/U - nephrostomy tube placed

Slide42 l.jpg

Lt UPJ obstruction


Diuretic renal scan processing l.jpg

Diuretic Renal ScanProcessing

  • 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 l.jpg

Diuretic Renal ScanWashout(diuretic response)

T1/2time required for 50% tracer to leave the dilated unit i.e. time required for activity to fall

to 50% of peak

T 1 2 washout l.jpg

T1/2 washout





T 1 2 value l.jpg

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)

T 1 2 l.jpg


  • 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 l.jpg

Diuretic Renal ScanInterpretation

  • Interpret whole study, not T1/2 alone

  • Visual (dynamic images)

  • Washout curve shape (concave vs. convex)

  • T1/2

Diuretic renal scan pitfalls l.jpg

Diuretic Renal ScanPitfalls

  • 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 l.jpg

Effect of catheterization (1)

full bladder,no catheter

Effect of catheterization 2 l.jpg

Effect of catheterization (2)

with catheter in bladder

Effect of catheterization 3 l.jpg

Effect of catheterization (3)

without catheter

with catheter

F minus 15 diuretic renogram l.jpg

“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 1987:10-14Upsdell, Br JUrol 1992:126-132

Evaluation of renovascular hypertension l.jpg

Evaluation of Renovascular Hypertension

Captopril Renal Scan (ACEI Renography)

Renovascular disease l.jpg

Renovascular Disease

  • Renal artery stenosis (RAS)

  • Ischemic nephropathy

  • Renovascular hypertension (RVH)

    RAS  RVH

Renovascular hypertension l.jpg

Renovascular Hypertension

  • Caused by renal hypoperfusion

    • Atherosclerosis

    • Fibromuscular dysplasia

  • Mediated by renin - AT - aldosterone system

  • Potentially curable by renal revascularization

Renovascular hypertension57 l.jpg

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 l.jpg

Renin-Angiotensin System




Angiotensin I



Angiotensin II



Effect of ras on gfr l.jpg

Effect of RAS on GFR

Diagnosis of ras l.jpg

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 l.jpg

ACEI Renography

Slide62 l.jpg

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 µg/kg iv (2.5 mg max), 15 min pre-scan

    • Monitor BP q 15 min

Acei renography procedure l.jpg

ACEI RenographyProcedure

  • 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 l.jpg

ACEI RenographyProcessing

  • Relative renal uptake (bkg corrected)

  • Time to peak (Tp) - from cortical ROI

    • normal < 5 min

  • RCA20 (20 min/peak ratio) - from cortical ROI

    • normal < 0.3

Slide66 l.jpg

ACEI RenographyGrading renogram curves

Acei renography diagnostic criteria l.jpg

ACEI RenographyDiagnostic 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 ‘96:1876Semin NM 4/99:128-145

Acei renography interpretation l.jpg

ACEI RenographyInterpretation

  • 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 l.jpg

Captopril Renal ScanMAG 3

Slide70 l.jpg

Captopril Renal Scan MAG3

Slide71 l.jpg

Captopril Renal ScanMAG 3

Slide73 l.jpg

Captopril Renal ScanMAG 3

Acei renography77 l.jpg

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 l.jpg

Evaluation of Renal Infection

Renal Morphology Scan (Renal Cortical Scintigraphy)

Slide79 l.jpg



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 l.jpg

Renal Cortical ScintigraphyIndications

Determine involvement of upper tract (kidney) in acute UTI (acute pyelonephritis)

Detect cortical scarring (chronic pyelonephr.)

Follow-up post Rx

Renal cortical scintigraphy procedure l.jpg

Renal Cortical ScintigraphyProcedure


Tc-99m DMSA

Tc-99m GHA


2-4 hrs post-injection

parallel hole posterior

pinhole post. + post. oblique (or SPECT)

Processing: relative fct

Renal cortical scintigraphy interpretation l.jpg

Renal Cortical ScintigraphyInterpretation

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 l.jpg

Renal Cortical Scintigraphy“Cold Defect “

Acute or chronic PN




Trauma (contusion, laceration, rupture, hematoma)


Dmsa parallel hole collimator l.jpg

DMSA parallel hole collimator

Slide85 l.jpg

Normal DMSA



Slide86 l.jpg


Acute pyelonephritis dmsa l.jpg

Acute pyelonephritisDMSA

post L



LPO pinhole


Renal cortical scintigraphy congenital anomalies l.jpg

Renal Cortical ScintigraphyCongenital Anomalies



Fusion (horseshoe, crossed fused ectopia)

Polycystic kidney

Multicystic dysplastic kidney

Pseudomasses (fetal lobulation, hypertrophic column of Bertin)

Dmsa horseshoe kidney l.jpg

DMSAhorseshoe kidney


Dmsa lt agenesis l.jpg

DMSALt Agenesis


Slide91 l.jpg

GHACrossed ectopia


Radionuclide cystogram l.jpg

Radionuclide Cystogram

Indications94 l.jpg


  • 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 l.jpg

Tc-99m S.C. or TcO4

via Foley

can do at any age

VUR during filling


Tc-99m DTPA or Tc-99m MAG3


no catheter

info on kidneys

need pt cooperation

need good renal fct





Direct cystography l.jpg

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 l.jpg

Lower radiation dose(5 vs 300 mrad to ovary)

Smaller amount of reflux detectable

Quantitation of post-void residual volume

Cannot detect distal ureteral reflux

No anatomic detail

Grading difficult

RN Cystogram vs. VCUG


Normal cystogram l.jpg

Normal cystogram

filling voiding post-void

Vur filling phase l.jpg

VUR - filling phase


Vur voiding phase post void l.jpg

VUR - voiding phase & post-void


Post void residual volume l.jpg

Post void residual volume

voided vol x post-void ctspre-void cts - post void cts

RV =

Slide102 l.jpg

Reflux nephropathy



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