RENAL SCINTIGRAPHY

Prepared and Presented byPaul Jolles, MD

Kidney Stone

Anatomy Kidneys to Urinary

Bladder

ureterolithiasis

INDICATIONS

• DIFFERENTIAL FUNCTION• GFR, ERPF• OBSTRUCTION• POST OPERATIVE EVALUATION• NEED FOR FREQUENT FOLLOW-UP• AZOTEMIA• CONTRAST ALLERGY

HISTORICAL BACKGROUND

CONTRAST UROGRAPHY FIRST CLINICALLY USEFUL

UROGRAM 1929: DR. MOSES SWICK (U.S.)

IVP Phase IInitial injectionDynamic

IVP Phase IICortical Transit

IVP Phase IIIExcretory

IVP Phase IIIExcretory

IVP Phase IIIExcretory

HISTORCAL BACKGROUND

1945: I-131 PRODUCTION (U.S.)1947: COLTMAN AND MARSHALL

(U.S.) KOLLMAN (GERMANY) SCINTLLATION COUNTER

(PMT)

HISTORICAL BACKGROUND

1952: OESSER , BILLION (GER) COLLECTED URINE 1955: TAPLIN, WINTER (U.S.) FIRST RENOGRAM 1957: ANGER CAMERA (U.S.)

Renal Agents •Contrast •PAH•HIPP•Others

RADIOPHARMACEUTICALS

• TUBULAR SECRETION• GLOMERULAR FILTRATION• CORTICAL BINDING• MIXED

TUBULAR SECRETION

EFFECTIVE RENAL PLASMA FLOW

I-131 ORTHIODOHIPPURATETc-99m MERCAPTOACEYTL-

TRIGLYCINE (MAG3)

I-131 HIPPURAN

20% FILTERED80% SECRETEDDOSE: 300 uCi

Tc-99m MAG3

TUBULAR SECRETION 90% FILTRATION 10% DOSE: 5-10 mCi

Tc-99m MAG3 IMAGING

FLOW (ARTERIAL) UPTAKE (NEPHROGRAM) EXCRETION (“CORTICAL

TRANSIT”)

GLOMERULAR FILTRATION

GLOMERULAR FILTRATION RATE

Tc-99m DIETHYLENETRIAMINEPENTAACETIC ACID (DTPA)

IODINATED CONTRASTGd-DTPA

Tc-99m DTPA

GLOMERULAR FILTRATIONMETAL CHELATOR

20% EXTRACTION FRACTIONDOSE: 5-20 mCi

Tc-99m DTPA IMAGING

FLOW (ARTERIAL) UPTAKE (NEPHROGRAM) EXCRETION (“CORTICAL TRANSIT”)

RENOVASCULAR HYPERTENSION

ABRUPT ONSET HTN <30>55 YRS SEVERE/MALIGNANT HTN

REFRACTORY HTN

RENOVASCULAR HYPERTENSION

EPIGASTRIC BRUITMOD HTN WITH VASCULAR DZACE INHIBITOR-INDUCED RF

RENOVASCULAR HYPERTENSION

<1% HYPERTENSIVE PATIENTSATHEROSCLEROSIS FIBROMUSCULAR DYSPLASIARAS NOT NECESSARILY RVH

CAPTOPRIL RENOGRAPHY

MEDICATION HISTORYDISCONTINUE ACE

INHIBITORSSERUM CHEMISTRY (BUN/Cr)

CAPTOPRIL RENOGRAPHY

ORAL AND IV HYDRATIONBP MONITORING

25 MG CAPTOPRIL ORALLY10 mCi MAG 3 AND LASIX

CAPTOPRIL RENOGRAPHY

PHYSIOLOGY OF RVHDIMINISHED RBF

RENIN-ANGIOTENSINEFFERENT ARTERIOLE

CAPTOPRIL RENOGRAPHY

PROLONGED TIME TO PEAKCORTICAL RETENTION >30%

BASELINE STUDY

LASIX RENOGRAPHY

EVALUATION FOR OBSTRUCTION

LASIX WASHOUT HALF TIME

LASIX WASHOUT T1/2

TIME FOR CLEARANCE OF ½ ACTIVITY FROM THE KIDNEY

AFTER LASIX

LASIX WASHOUT T1/2

NORMAL: <10-15 MINOBSTRUCTED: >20 MIN

DILATED, NON-OBSTRUCTED

• PROGRESSIVE PELVOCALEAL TRACER ACCUMULATION

• PROMPT LASIX WASHOUT

DILATED, OBSTRUCTED

• PROGRESSIVE PELVOCALYCEAL TRACER ACCUMULATION

• IMPAIRED LASIX WASHOUT

IMPAIRED FUNCTION

RENAL FAILURE S/P AAA REPAIRTc-99m MAG3

• FLOW• UPTAKE• CORTICAL TRANSIT• EXCRETORY PHASE

CORTICAL BINDING

Tc-99m DIMERCAPTOSUCCINIC

ACID (DMSA)

Tc-99m DMSA

METAL CHELATOR50% CORTICAL BINDING VIASULFHYDRYL LINK (MAINLY PCT) 6% EXTRACTION FRACTION DOSE: 2-5 mCi

Tc-99m DMSA

PYELONEPHRITIS RENAL MASS

MIXED

Tc-99m GLUCOHEPTONATE

Tc-99m GLUCOHEPTONATE

12% CORTICAL BINDING (PCT)GLOMERULAR FILTRATION

TUBULAR SECRETIONDOSE: 10 mCi

GALLIUM SCINTIGRAPHY

• INTERSTITIAL NEPHRITIS• ACUTE RENAL FAILURE• ACUTE TUBULAR NECROSIS• AMYLOIDOSIS• VASCULITIS• CHEMOTHERAPY

GALLIUM SCINTIGRAPHY

• BILATERAL MALIGNANCY• LEUKEMIA, LYMPHOMA• BILATERAL OBSTRUCTION• NEPHROTIC SYNDROME• PYELONEPHRITIS• TUBERCULOSIS• WEGENER’S GRANULOMATOSIS