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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
Renal Function
Blood
secretion
Tubular
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
Procedure
Patient Preparation
Patient
before injection
Void @ end of study
Intl Consens. Comm.
Semin NM 99:146-159
Acquisition
Supine
Do
position preferred
Flow
Dynamic:
Acquisition (contd)
Obtain
do not report
Obtain
International Consensus
Committee Recommendations for
Basic Renogram
Collimator: LEAP
DTPA normal
DTPA normal
Relative uptake
Contribution
% Lt kid =
Normal
Borderline
Abnormal
50/50 - 56/44
57/43 - 59/41
> 60/40
Taylor, SeminNM Apr 99
Processing
Time
to peak
Urine Volume
GFR = 29 ml/
Creat = 2.0
L= 33%
R= 67%
Rt renal infarct
Renogram Phases
I.
II.
III.
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)
Principle
Hydronephrosis
renal pelvis
Lasix
If
If
Can
Indications
Evaluate
functional significance of
hydronephrosis
Determine
effect of therapy
Requirements
Rapidly
Well
cleared tracer
hydrated patient
Good
renal function
Procedure
Pt.
preparation:
prehydration
adults - oral or 360ml/m2 iv over 30
peds - 10-15 ml/kg D5 0.3-0.45%NS
Procedure (contd)
Tracers:
Acquisition:
Flow
Dynamic:
Procedure (contd)
Lasix:
Procedure (contd)
Dont
give Lasix if
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
Lt hydronephrosis
3164897
Lt UPJ obstruction
3164897
Rt UPJ obstruction
T1/2
R = N/A
Lt UPJ obstruction
3164897
Processing
ROI
placement
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
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
Interpretation
Interpret
Visual
(dynamic images)
Washout
T1/2
Pitfalls
False
Distended bladder
Gross hydronephrosis
T(transit time) = V (volume) F (flow)
negative
full bladder,
no catheter
with catheter
in bladder
without catheter
with catheter
F minus 15
Diuretic Renogram
Furosemide
Rationale:
Some
Evaluation of
Renovascular
Hypertension
Captopril Renal Scan
(ACEI Renography)
Renovascular Disease
Renal
Ischemic
nephropathy
Renovascular
RAS RVH
hypertension (RVH)
Renovascular
Hypertension
Caused
by renal hypoperfusion
Atherosclerosis
Fibromuscular dysplasia
Mediated
Potentially
Renovascular
Hypertension
Prevalence
features
Renin-Angiotensin System
Angiotensinogen
RAS
Renin
Angiotensin I
Captopril
ACE
Angiotensin II
Aldosterone
Vasoconstriction
HTN
Diagnosis of RAS
Gold
std: angiography
Initial
non-invasive tests:
ACEI renography
Duplex sonography
Other
tests:
ACEI Renography
ACEI Renography
Patient Preparation
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:
Protocol:
ACEI Renography
Processing
Relative
Time
ACEI Renography
ACEI Renography
Diagnostic Criteria
MAG3:
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:
ACEI Renography
Interpretation
High
probability RVH
ACEI Renography
In
Evaluation of Renal
Infection
Renal Morphology Scan
(Renal Cortical
Scintigraphy)
UTI
VUR
Indications
Determine
Follow-up
post Rx
Procedure
Tracers
Tc-99m DMSA
Tc-99m GHA
Acquisition
relative fct
Interpretation
Acute
PN
PN
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
Congenital Anomalies
Agenesis
Ectopy
Fusion (horseshoe, crossed fused ectopia)
Polycystic
kidney
Multicystic
dysplastic kidney
column of Bertin)
DMSA
horseshoe kidney
parallel
pinhole
DMSA
Lt Agenesis
parallel
GHA
Crossed ectopia
74%
26%
Radionuclide
Cystogram
Indications
Evaluation
Assess
Screening
Methods
Direct
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
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
RV =
Reflux nephropathy
16%
84%