klinika nukleární medicíny a endokrinologie uk 2. lf a fn motol renal radionuclide studies...
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Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
RENALRADIONUCLIDE STUDIES
Kateřina Michalová
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Radionuclide diagnostics methods
Noninvasive
Are primarily physiologicFunctional
Does not provide the same anatomic details as morphologic method (X-ray,US,CT,MRI)
Kupka K .a kol: Nukleární medicína, 2002
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Nuclear renal imagingincludes these methods
1. Renal dynamic scintigraphy
2. Renal cortical scintigraphy
3. Radionuclide Cystography
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Dynamic renal scintigraphy
Is a functional examinationProviding information about intrarenal kinetics
Of the i.v. applied radiopharmaceuticalAnd of its transport via the efferent urinary tracts
The specific information obtained depends of radiopharmaceutic injected.
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Dynamic renal scintigraphy
There are two kinds of
Radiopharmaceticals: a) Tubular agents 99mTc-MAG3 Mercapto-acetyltriglycin 131I -,123I-Ortoiodhippurate b) Glomerular filtration rate agens 99mTc-DTPA Diethylentriamine pentaacetic acid
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
RadiopharmaceuticalsMechanisms of excretion
you can see in the picture
Glomerular filtration• 99mTc DTPA• Tubular secretion• 99mTc MAG3• 131I, 123I – OIH
Tubular fixation• 99mTc DMSA• 99mTc glucoheptonate
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Radiopharmaceticals
99mTc-DTPA – Diethylentriamine pentaacetic acid
belongs to the group of chelate compounds is excreted from kidneys through glomerular filtration with a half-life of 70 minutes it is the most suitable substance for measuring glomerular filtration (GFR) and good imaging of renal parenchyma
Vižďa J. a kol : Atlas of Renal Scintigraphy, 2002.
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Radiopharmaceticals
99mTc-MAG3 - Mercapto-acetyltriglycine -is one of the newly developed radiopharmaceuticals-is rapidly excreted by the kidneys via active tubular secretion and minor part via glomerular filtration -organic anions (which include MAG3) have a carboxyl group which specifically binds to the receptors of tubular cells mediating the active transport of MAG3 into the cells of the proximal tubulus-with normaI renal function 70% of the administered activity of the radiopharmaceutical (RP) is excreted within 30 minutes after the application
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Dynamic renal study
Radiopharmaceutical 99mTc - MAG3
Patient Preparation adequately hydration prior to the examination it is recommended to drink 100 ml of liquids per 10 kg of the body weight 30 min prior the examination empty bladder p.are requested to void completely prior to the study
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Dynamic renal study Image Acquisition p.is usually examined in the supine position sometimes in sitting position detector of the gamma camera is in the posterior projection field of view includes the area of kidneys, ureters and the area of the bladder
data recording starts immediatelly before the intravenous injection
as serial 15 sec images for 20 min radionuclide angiography 1 s frames are recorded for a period 1 minut after the administration of the RF can be used in examination of kidney grafts
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Evaluation
• visuel
• parenchymal phase
• position
• size
• shape
• distribution RF
• excretory phase
• dilatation of the collecting system
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Summed image of all frames during the clearance phase
ROI (regions of interest) are drawnRenal ROI – arround the kidneyBackground ROI–below the kidney
Computer processing of the study
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Renogram curves
Computer processing of the study
Parameters of the curves
Tmax = time ofachieving the peakof the curve
T1/2 = intervalbetween the time ofachieving the peakof the curveand the decreaseto 50% of the peaklevel
Time activity curves derived from renal ROI
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Computer processing of the study quantitation of the individual renal functiondifferential renal function DRFcalculated within 1 to 3 minutes post injection of RPphysiological range is 45%-55%
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Normal renogram curve
A
II. III.
I.
I. Vascular phase II. Secretory
III. Excretory
čas
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
A
čas
normal
obstructed pattern
impaired renal functionparenchymal lesion pattern
renal failure patternwithout measurable kidney uptake
renal failure patern
Patterns of renographic curves
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Dynamic renal study
Indications All uropaties, which require evaluation of individual renal
function at diagnosis and during the different phases of surgical or conservative treatment
and evaluation of the drainage function
Examples include dilatation of the cause (e.g.Pelvi-Ureteric and Vesico-Ureteric dilatation), bladder dysfunction, complicated duplex kidney, post trauma, asymetrical renal function and reflux nefropathy.
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Diuretic Renography The purpose of diuretic renography is to differentiate a true obstruction from a dilated non obstructed system (stasis) by serial imaging after intravenous administration of furosemide (Lasix)) 1) Standart renogram When dilatation of the collecting system exists, standart renogram should be complemented by a diuretic renogram 2) Diuretic renogram – additional 15-20 min acquisition, using the same technique as above Furosemid - 1mg/kg with a maximum dose 20mg (40 mg dle *SNM) *Society of Nuclear Medicine Procedure Guadeline for Diuretic Renography in Children
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
A
čas
non obstruction dilatation (hypotonie stasis)rapid washout fromthe collecting system
obstruction no response to a diureticno washout of RP from the collecting system
Furosemid i.v.
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Diuretic renography Indications differentiation obstructive from non obstructive causes of hydronephrosis and hydroureteronephrosis
Ureteropelvic or ureterovesical obstruction Prenatal ultrasound diagnosis of hydronephrosis Post-surgical evaluation of the previously obstructed system Distension of pelvicalyceal system as an etiology of back pain
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
no obstruction
non obstruction dilatation (hypotonie stasis)rapid washout fromthe collecting system
furosemidverticalposition
Left kidney -enlarged-dilated collecting systemwith pronouncedretention of urine-response tothe diuretic israpid
Right kidneynormal shapecollecting systemwith pronouncedretentin of urine-response to the diuretic is rapid
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
obstructionpoor response to a diureticno washout of RP from the collecting system
Left kidney -enlarged-dilated collecting systemwith pronouncedretention of urine-poor response tothe diuretic
Right kidneywashoutof urine is freeby nefrostomy
furosemidverticalposition
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
obstructionno response to a diuretic
Right kidney -enlargedhypofunctionalimpresionof dilatated collecting isseen, but no good fiilingno response to a diuretic
Left kidney normal
severe obstructionno response to a diureticno washout of RP from the collecting system
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Renal Cortical Scintigraphy
Static imaging of the kidney
Radiofarmaceutical : 99mTc-DMSA Dimercaptosuccinic acid
Following iv injection is taken up into the renal cortex in the proximal convoluted tubule.The main site of accumulation are the micro somes of the cells of
proximal tubules.
It is cleared slowly , urine exrection is low.
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Renal cortical scintigraphy
Patient Preparation no
Image Acquisition static high resolution images of kidneys (ANT, POST, RPO, LPO projection) SPECT in the supine position
2,5 h after injection DMSA cleared slowly (high radiation dose versus DRS !!!)
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Renal cortical scintigraphy
Common Indications1. Acute pyelonephritis2. Renal scarring3. Relativ functioning renal mass 4. Solitary or ectopic renal tissue (e.g.,pelvic kidney)4. Horseshoe and pseudohorseshoe kidneys5. Allergie to iodinated contrast agents
Society of Nuclear Medicine Procedure Guideline for Renal Cortical Scintigraphy in Children
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Renal cortical scintigraphy
- is used for detection of cortical defects of acute pyelonephritis (loss of function) and scarring related to chronic pyelonephritis.
- is able to detect twice as many defects as ultrasound 4 times as many defects as intravenous urography- computed tomography has sensitivity and specificity similar but adds to the risk of contrast reaction and has a higher radiationexposure- magnetic resonance imaging is promising but expensive nonionizing method of vizualizing pyelonephritis
Society of Nuclear Medicine Procedure Guideline for Renal Cortical Scintigraphy in Children
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
ANT POST
RPO LPO
Normal renal scan
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Evaluation- number of kidneys- position- size- shape- the size, number and location of areas cortical loss- split renal function
Note!
Cortical „cold“ defect may be due to
different etiology :
tumor, abscess, cysts ….
alrealdy is necesarry to compare with US
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Evaluation of split renal function- for determination of percent differential function regions of interest of each kidney and background area are outlined on the computerized posterior and anterior images.
- split renal function normally varies from 45%-55%
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Acute pyelonephritis(multifocal)
-more foci of reduced accumulation of the RP
-diffuse damage to the parenchyma
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Scarring
2-years old girl after repeated infection of uropoetic system
ANT POST
RPO LPO
characterized as :-wedshaped defects-with thinningor flattening of the cortex-irregularmargins-loss of volumeof the kidney
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
ANT POST
dystopia
Anomalies of position and number
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Direct Radionuclide CystographyMicturating cystography (MCG)
-The examination is performed in the same way as X-ray MCG-Requires catheterization of the bladder and instilation of radionuclide and fluid for maximal physiological distension of the bladder, -Allowing imaging (dynamic scintigraphy) during filling, voiding, and after voiding. Radiopharmaceutical 99mTc- MAG3 Patient preparation no Time of examination 1 h
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Direct Radionuclide Cystography
Common Indication Screening and therapy monitoring vesicoureteral reflux Diagnostic of familiar reflux
Evaluation of vesicoureteral reflux after medical management Assesment of resuls of antireflux surgery
Comparing with conventional radiographic technique (X-ray MCG)• less gonadal radiation (100-200x lower than X-ray MCG)
• higher sensitivity for detection of vesicoureteral reflux• does not provide the same anatomic details as X-ray MCG
Society of Nuclear Medicine Procedure Guideline for Radionuclide Cystography in Children
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Direct Radionuclide Cystography
Vezikoureteral reflux
Interpretation criteria
Grade
I. with activity limited to the ureter II. with activity reaching the collecting system with none or minimal activity in ureter III. with a dilatation of the collecting system and dilated ureter
Society of Nuclear Medicine Procedure Guideline for Radionuclide Cystography in Children
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
Visual evaluationNormal patternno activity is recorded in the ureters
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
VUR grade I (into ureter)
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
VUR grade II (into collecting system of the kidney)
Klinika nukleární medicíny a endokrinologie UK 2. LF a FN Motol
VUR grade III (into collecting system of the kidney with a dilatation)
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