RENOGRAMS

RCA AND OCA

ESTIMATION OF SPLIT RENAL FUNCTION

a) MAG3 - F0 Study: from the 2d minute counts – BK

b) New accurate method with MAG3 in obstruction

c) MAG3 SPECT (2d + 3d min data)

d) DMSA SPECT after attenuation correction

e) Anterior+Posterior DMSA Planar (Geometric Mean)

f) DTPA may mislead due to the low Extraction Efficiency

and Confusing High Blood Pool Activity

QUANTIFICATION OF GLOBAL RENAL FUNCTION

a) Blood and Urine Sampling (Classic Clearance)

b) Blood sampling (Distribution Space Model)

c) Kidney Uptake to Dose Count Ratio

d) Bladder Activity to Dose Count Ratio

e) Kidney to Background Ratio / RCA

Current research on renal function

To develop a method to calculate from the MAG3-F0 studyTHE RENAL GLOBAL FUNCTION (RGF) we use:

a) The Kidney Uptake/Body Background Activity (at 2 min)

b) The Residual Cortical Activity (at 20 min)

Both these parameters are related with the creatinine levels

Current research on renal function

The Kidney Uptake/Body Background Activity (at 2 min)

HOW FASTTHEY FILL

RENAL FUNCTION DEPENDS ON TUBULES

HOW WELLTHEY EMPTIE

Global Renal Function Calculations

ln Creatinine = 1.22 – 0.55 * ln GRF

e 1.22

Creatinine =(GRF) 0.55

3Creatinine ≈

GRF

MAGMAG33--FF00

Results: Correlation of ln of Creatinine with ln of GRF

-2

-1

0

1

2

-2 -1 0 1 2 3 4 5

ln RGF

ln C

reat

inin

e

ln Creatinine = 1.22 – 0.55 * ln GRF

ln GRFMAGMAG33--FF00

Natural Algorithms

Results: Prediction of Creatinine levels by the Formula GRFComparison with real Creatinine values

0

1

2

3

4

5

6

7

0 1 2 3 4 5

Predicted Creatinine

Cre

atin

ine

6 MAGMAG33--FF00

NORMAL STUDIES

AGE RELATED VARIATIONS

Misunderstanding

Ye have heard that it was said by them of old time:You cannot image the kidneys of a newbornYou need to catheterize the urinary bladder

to exclude obstruction

But we say unto you MAG3 works in the Newborn and the Infant and you do not need to use a bladder catheter

Typical NORMAL MAG3-F0 in a NEWBORNIndication: Evaluate Pelviectasis found by Ultrasound

No Obstruction; Slight Immaturity; Study Normal for AgeThe infant urinated twice ( ) during study = No need for catheter

Typical NORMAL MAG3-F0 in a NEWBORNIndication: Evaluate Pelviectasis found by Ultrasound

Normal study; Slight Immaturity, Bladder does not empty

MAG3-F0 in a 10 yo CHILD; Mature Normal KidneysIndication: Evaluate effects of urinary infection

Slight discrepancy in size and function (effect of infection on the right kidney)

Normal MAG3 - F0 in an ADULTIndication: Renal Colic

Misunderstanding

Ye have heard that it was said by them of old time:You cannot do tomography with MAG3

But we say unto you MAG3 can do tomography within 4 minutes

NORMAL MAG3-F0 SPECT (tomogram)tomograms axial/coronal/sagittal

35yo female with history of pyelonephritis

Axial

Coronal

Sagittal

RENAL SCINTIGRAPHY

DIURETIC STUDIES

DIURECTIC RENOGRAPHY:to make the diagnosis of Kidney Obstruction

WHITAKER TEST

At 10 ml/min infusiona renal pelvis pressure>10 cm water from the pressure in the bladder defines obstruction

Problem 1:It is an invasive method

Problem 2: Many kidneys cannot produce 10 ml/min urine (hypofunctioning) = FP

DIURETIC RENOGRAPHY

INDICATIONS

1) TO DIFFERENTIATE BETWEEN

DILATATION WITHOUT OBSTRUCTION

AND PARTIAL OBSTRUCTION

2) TO CONFIRM COMPLETE OBSTRUCTION

PRINCIPLE

Diuresis (completely) washes out the activity

when there is no obstruction

but fails to do so in obstructive uropathy

MisconceptionFor Diuretic Renography you need to inject the diureticeither 20-30 min after MAG3 (old O’Reily=F+20/30 )

or 15 min before MAG3 (new O’Reily =F-15 )

Fact You can inject MAG3 and Lasix Simultaneously (F0 )

DIURETIC RENOGRAPHY

TIMING OF DIURETIC INJECTION

F+20 : 20-30 min POST MAG3 (old O’Reily)(40-50 min study time)

F-15 : 15 min PRE MAG3 ……(new O’Reily)(35-40 min study time)

F0 : SIMULTANEOUSLY with MAG3 (UM)

(22 min study time)

COMPARATIVE STUDY OFTHE TIMING OF DIURETIC INJECTION

UM/JMH PRESENTED SNM AM 2000

20 min

15 min

(0 min)

(20 min)

(35 min)

COMPARATIVE STUDY OFTHE TIMING OF DIURETIC INJECTION

UM/JMH PRESENTED SNM AM 2000

MAG3 F+20 MAG3 F-15 HIP F0

DIURETIC RENOGRAPHY with the THREE METHODS: Results: Equivalent

Radiation Exposure: Higher with F+20

40+ min 40 min 22 minDuration of the Examination

Lasix

ZERO TIME INJECTION DIURETIC RENOGRAPHY (F0):

• It is at least as Accurate as F+20/30 and F-15

• Better Tolerated (Shorter – One Injection)

• Fewer interruptions in adults for voiding

• Cost Effective as it is Concluded in 25 min

• Reduces the Radiation Exposure of the Patient

• It Allows The Evaluation of the Parenchyma

RENAL SCINTIGRAPHY AT UM/JMMC: (MAG3-F0) Method applied the last 18 years:

In applying this Protocol New Horizons were realizedfor prompt, easy and reliable evaluation of the drainagebut also of the function of the renal parenchyma

Many Misconceptions were also exposed and challenged

ZERO TIME INJECTION DIURETIC RENOGRAPHY (F0):

• It Allows The Evaluation of the Parenchyma

NORMAL MAG3WITHOUT DIURETIC (F+20)

Cortex full of urinecannot be studied effectively

NORMAL MAG3WITH DIURETIC (F0)

Cortex emptycan be studied effectively

Diuretic F0

Diuretic F+20

RENAL SCINTIGRAPHY AT UM/JMMC: (MAG3-F0) Method applied the last 18 years:

This protocol was originally applied in the evaluation of drainage

Soon it was realized that it allowed the evaluation of the parenchyma

Then it was applied in all parenchymal indications (including APN)

It was also utilized for the study of Renovascular Hypertension

It allowed the study of HIV and other Acquired Nephropathies

In patients with renal colic unraveled the Stunned (decompressed) kidney

It was finally successful in the study of complications of renal transplants

RENAL SCINTIGRAPHY IN THE 21st CENTURY99mTc- MAG3 with zero time injection of Furosemide (MAG3-F0) :

A Fast and Easy Protocol, One for All Indications

Clinical Experience

THE VALUE OF MAG3 -F0 DIURETIC RENOGRAPHY IN PREDICTING THE NEED FOR SURGERY IN THE NEONATE WITH

URETEROPELVIC JUNCTION OBSTRUCTION

Sfakianakis G, Vensel E, Tapia M, Policaro F, Gosalbez R, Labbie A, Zilleruelo G, Abitbol C, Montane B, Strauss J

Abstract: SNM 2000

Duplication with Ectopic Ureter Ureterocele and Upper Moiety Obstruction

Traditional concept:To make the Diagnosis of Obstruction you need to Study the Collecting System of the Kidney

New Horizons: To make the Diagnosis of Obstruction you better study the behavior of the Renal Cortex:

If the cortex empties, there is no obstruction! (even when the drainage system is dilated

and it does not empty appropriately)

(Contributions by Dr Gonzalbez and Dr Bourgoignie)

EXTRARENAL PELVIS without OBSTRUCTIONNewborn

17 month old

In the presence of a dilated, abnormal collecting systemThe Non-Obstructed Cortex Empties

The Obstructed Cortex does not empty

Case No 1

min min

left right left right

IF THE CORTEX EMPTIES, THERE IS NO OBSTRUCTION

Left: Non-obstructed; Right: Obstructed

Evaluation of Acute Focal Pyelonephritis with Dynamic MAG3 -F0

At the University of Miami / JMH

THE ISSUE OF ACUTE PYELONEPHRITISHAS BEEN SET

Forget the old 4 hours DMSA studies

IF THE CORTEX EMPTIES, THERE IS NO ACUTE PYELONEPHRITIS

Acute Pyelonephritis by MAG3-F0“Regional Parenchymal Dysfunction”

Acute Focal Pyelonephritis with MAG3-F0

8yo child with SCD and pain, fever and positive urinalysis

2 min 4 min 6 min 8 min

18 min 20 min 22 min Post Void

ZERO TIME INJECTION DIURETIC RENOGRAPHY (F0):

• It Allows The Evaluation of the Parenchyma

for diffuse or focal disorders

diffuse focal

HIV-Nephropathy

20 min Retention of activity = good prognosis for recovery, recently verified

DIFFERENTIATION AND F/UOF DIFFUSE PARENCHYMAL DISEASES

• ETIOLOGY OF ACUTE RENAL FAILURE

• DIFFERENTIATION FROM CHRONIC RF

• EVALUATION OF FUNCTION OF KIDNEYS

• PROGNOSTIC INFORMATION (RECOVERY?)

STUDY OF RENAL INSUFFICIENCY/FAILURE

• Acute Tubular Necrosis

• Nephrotoxicity

• Nephritic/Nephrotic Syndromes

• HIV-Nephropathy

• Chronic Renal Failure

Patient s/p septic shock. Prognosis: Recovery (retention of activity )

Acute Tubular Necrosis with MAG3(relative preservation of renal blood flow )

Acute Renal Failure due to Nephrotoxicity

Patient with liver transplant and high creatinine r/o obstructionPrognosis: Recovery (retention of activity )

Chronic Renal InsufficiencyHypertension

Prognosis: No recovery (No retention of activity )

HIV Nephropathy in Children

Upper: Normal study, Middle Moderate HIVN, and Lower: Severe HIVN

20 min Retention of activity = good prognosis for recovery, recently verified

Moderate disease

Severe disease

2 min 10 20

2 min 10 20

2 min 10 20

Normal kidneys

ACE-Inhibition scintigraphy

MAG3 - F0 in Renovascular HypertensionDiagnostic Criteria

Criterion A

Criterion B

Criterion C Non Functioning

No Change

Deterioration

CRITERION A:

ACE-I: DETERIORATIONof Renal Function

Compensated RA Stenosis, 70-95% of the lumen

Angioplasty effectivein reducing HT

Do not use ACE-I for treatment of HT

ACE-InhibitionBaseline

2 min 4

10 12

18 20

2 min 4

10 12

18 20

Criterion A

Successful Angioplasty, Patient Normotensive

MAG3-F0 in RENAL COLIC

PAIN

EFFECTS OF OBSTRUCTIONRIGHT COLIC: R. KIDNEY ACUTE COMPLETE OBSTRUCTION --- NO TREATMENT

LEFT COLIC: BILAT COMPLETE OBSTRUCTION: R. = OLD; L. = ACUTE -- DRAINAGE

LEFT COLIC: RIGHT KIDNEY ATROPHY; LEFT KIDNEY PARTIAL OBSTRUCTION

RENAL SCINTIGRAPHY IN THE 21st CENTURY99mTc- MAG3 with zero time injection of Furosemide (MAG3-F0) :

A Fast and Easy Protocol, One for All Indications