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IN KIDNEY DISEASES :
INDICATIONS AND
INTERPRETATIONS
20-5-13
Isotopes
Any given element may have many isotopes
All isotopes of a given element have the same no of
protons and differ only in the no of neutrons
Some of these isotopes have unstable nuclear
configuration and seek greater stability by
decay/disintegration to a more stable form
Isotopes attempting to reach stability by emitting
radiation are called radionuclides/radioisotopes
Radionuclides
Photon Emitting(imaging) – Tc99m;
Mo99;I123;Ga67;In113;Kr81;Th201
Positron Emitting(imaging)
C11;N13;O15;F18;Rb82
RADIOPHARMACEUTICALS =
RADIONUCLIDES + PHARMACEUTICAL
NUCLEAR SCINTIGRAPHY
TECHNIQUES
2D Scintigraphy - use of internal radionuclides to create two-
dimensional images.
Radionuclide cystogram
Renal scintigraphy
INDICATIONS
Renal perfusion and function
Urinary Tract Obstruction (Furosemide renal scan)
Reno-vascular HTN (Captopril renal scan)
Infection (renal morphology scan)
Pre-surgical quantitation (nephrectomy)
Renal transplantation
Congenital anomalies/masses(renal morphology
scan)
Radiopharmaceutical Agents
Grouped into three categories:
1. Those excreted by glomerular filtration,
Tc 99m DTPA
51Cr-EDTA
I 125 Iothalamate
Glomerular Filtrating Agents
Tc-99m DTPA
(Diethylenetriamine pentaacetic acid)
COOH
COOH
N
HOOC N
N
COOH
COOH
Tc 99m DTPA
• Inulin clearance remains the gold standard to
measure GFR, but it is expensive, time
consuming, and requires a steady-state plasma
concentration and accurate and timed urine
collection
• 99mTc-DTPA is recommended agent is for
GFR measurement.
• 5- 10% plasma protein binding, so it tends to
underestimate the GFR(insignificant)
• Peak renal activity after 3 – 4 min.
• 90 % filtered within 4 hours.
• The extraction fraction of 99mTc-DTPA is
approximately 20 per cent; for this reason,
not useful for imaging , in patients with
impaired renal function.
• In such cases, agents with higher extraction
efficiencies such as 99mTc-MAG3 more
appropriate.
51Cr-EDTA, which may provide more accurate
values for GFR, but cannot be used for
imaging.
Tubular secreting agents:
I131/I123 OIH
Tc99m MAG3
Tc99m EC
Proximal convoluted
tubules
p-Aminohippuric acid (PAH) is the gold
standard for the measurement of ERPF.
However, it is not well suited for routine studies.
I-131/I-123
Orthoiodohippurate
-C-NH-CH2-COOH
CH2-COO
S O N
Tc
O
N N
O
Tc99m MAG3
70 – 90 % PROTEIN BINDING
89% TUBULAR SECRETION
11% GLOMERULAR FILTRATION
Extraction fraction of 40-50%.
Provides a high target-to-background ratio, good
image quality, and more accurate numerical
values, particularly when the kidney function is
low or immature
5 TO 10 mCi i.v. ( ADULTS)
Tc99m L,L-EC
(Ethylene dicysteine)
N N
-ooc coo-
Tc
S S
Tc99m GHA
Tc-99m DMSA
(Dimercaptosuccinic Acid)
HS COOH
HS COOH
H
Cortical agents
Tc99m DMSA-
PYELONEPHRITIS, INFARCTS, SCARS, ANOMALIES
75% protien binding in 6 hrs
5- 20 % excretion 2 hrs
37% excretion in 24 hrs
40-50% cortical localisation
Maximum activity at 3-6 hrs
2 TO 5 mCi i.v.
Images at 2 – 4 hrs
Importantly, acute infection can produce
abnormalities in the scan; and if the test is being
performed to evaluate for cortical scarring, it
should be done at least 3 months after an acute
infection ( Rosenberg et al, 1992 ).
Tc 99m GHA
(Glucoheptonate)
O
O O O
O
C Tc C
CH CH
O O
(CHOH)4 (CHOH)4
CH2OH CH2OH
CONTD..
Tc 99m GH
It is both filtered by the glomerulus and bound by
the tubules.
Glomerular filtration 80-90%
Tubular secretion 10-20%
25-40% in 1 hr & 70% in 24 hrs in urine
15% bound to PCT
EARLY DYNAMIC FUNCTIONAL imaging
DELAYED CORTICAL imaging
10-15 mCi
Choosing Renal Radiotracers
Procedure
Basic Renal Scintigraphy
Patient Preparation
Acquisition
Acquisition (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
NORMAL FINDINGS
Smooth contour with Homogeneous activity
Less uptake in medulla
No activity in PCS
Diuretic (Furosemide) Renal Scan
Renovascular Disease
Renal artery stenosis (RAS)
Ischemic nephropathy
Renovascular hypertension (RVH)
RAS RVH
Renin-Angiotensin System
RAS
Angiotensinogen
Renin
Angiotensin I Captopril
ACE
Angiotensin II
Aldosterone Vasoconstriction
HTN
Effect of RAS on GFR
Renovascular Hypertension
Prevalence
<1% unselected population with HTN
Clinical features
Abrupt onset HTN in child, adult < 30 or > 60y
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%)
Diagnosis of RAS
Indications
Determine involvement of upper tract
(kidney) in acute UTI (acute pyelonephritis)
Detect cortical scarring (chronic pyelonephr.)
Follow-up post Rx
CONTD..
gold standard 99mTc DMSA
The radiotracer is taken up only by functioning
PCT mass
Pyelonephritis impairs tubular uptake of
radiotracer, these areas appear as unexposed or
underexposed
Persisting areas on follow up indicates
irreversible renal damage or scarring.
Renal Cortical Scintigraphy
Cold Defect
Acute or chronic PN
Cyst
Tumors
Infarct
Trauma (contusion, laceration,hematoma)
Ectopy
Polycystic kidney
Transplant kidney is
showing poor perfusion,
uptake and drainage of
radiotracer- Chronic
Rejection
INDICATIONS PROs
Assess effect of therapy More sensitive
Evaluation of children
deleniation
with recurrent UTI
(30-50% have VUR)
Radionuclide Cystogram
Refrences
Oxford text book of clnilcal nephrology-3rd ed.
Essentials of Nuclear Medicine Imaging –
Mettler & Guiberteau
Brenner and Rector’s The kidney– 9th ed.
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