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RENAL SCINTIGRAPHY in the 21St CENTURY

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RENAL SCINTIGRAPHY in the 21St CENTURY RENAL SCINTIGRAPHY IN THE 21st CENTURY 99m Tc- MAG3 with zero time injection of Furosemide (MAG3-F0) : A Fast and Easy Protocol, One for All Indications Clinical Experience Congenital Disorders PROTOCOL FOR MAG3 - F0 PATIENT PREPARATION Easy (only restriction, oral hydration, no bladder cath.) DYNAMIC STUDY (iv 1-10 mCi MAG3 + 40-80 mg LASIX) Simultaneous injection of Furosemide: MAG3-F0 Duration of the study 25 min TOMOGRAPHY-SPECT (20 mCi MAG3) No diuretic needed Duration of the study 4 min RENAL SCINTIGRAPHY AT UM/JMMC: (MAG3-F0) Method applied the last 18 years: FOR NATIVE KIDNEY STUDIES FOR RENAL TRANSPLANT STUDIES RENAL SCINTIGRAPHY AT UM/JMMC: (MAG3-F0) Method applied the last 18 years: A. DYNAMIC STUDY Injection iv 1-10 mCi MAG3 + 40-80 mg LASIX (Furosemide) Simultaneous Injection of MAG3 and Lasix = F0 ACQUISITION: FLOW: 1 min ( 1 frame per 1 sec) FUNCTION: 22 min ( 1 frame per 30 sec) POST VOID 2 min static image (at 25-30 min) DELAYED 2 min static images (at 1 hr) GROUPING IMAGES : -FLOW: in 3 sec images -FUNCTION: in 2 min images GRAPH GENERATION: -FLOW/FUNCTION, KIDNEY/CORTEX 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 In children allowed the study of HIV and other Nephropathies In patients with renal colic unraveled the Stunned (decompressed) kidney It was finally successful in the study of complications of renal transplants MAG3-F0 PROTOCOL Misconception • You cannot image the kidneys of a newborn • You need to catheterize the urinary bladder to exclude obstruction Facts • MAG3 -F0 works in the Newborn Infant • You do not need to catheterize the urinary bladder Typical NORMAL MAG3-F0 in a NEWBORN Indication: Evaluate Pelviectasis found by Ultrasound Normal study; Slight Immaturity, Bladder empties Typical NORMAL MAG3-F0 in a NEWBORN Indication: Evaluate Pelviectasis found by Ultrasound Normal study; Slight Immaturity, Bladder does not empty MAG3-F0 in a 10 yo CHILD; Mature Normal Kidneys Indication: Evaluate effects of urinary infection Slight discrepancy in size and function (effect of infection on the right kidney) Normal MAG3 -F0 in an ADULT Indication: Renal Colic INDICATIONS FOR MAG3-F0 STUDIES: DIAGNOSIS - PROGNOSIS - FOLLOW UP • PARENCHYMAL OR DRAINAGE DISORDERS • IN CONGENITAL OR ACQUIRED DISEASES • FOR NATIVE OR TRANSPLANTED KIDNEYS • AT ALL AGES AND FUNCTIONAL STATES CONGENITAL URINARY TRACT ANOMALIES MAG3-F0 Dynamic Studies Diagnosis-Prognosis-Follow up MOST COMMON INDICATIONS FOR RENAL SCINTIGRAPHY NEONATE • CONGENITAL RENAL INSUFFICIENCY/FAILURE PERINATAL COMPLICATIONS WORK UP OF SONOGRAPHIC FINDINGS MASSES IN THE ABDOMEN SEARCH FOR AND EVALUATION OF CONGENITAL UT ANOMALIES Diagnosis-Prognosis-Follow up MAG3 -F0 in Congenital Renal Insufficiency or Failure Posterior Urethral Valves Bilateral Agenesis Bilateral Dysplasia CONGENITAL RENAL INSUFFICIENCY/FAILURE Bilateral Obstruction Early Correction of UPJO (the first week of life) may Prevent Loss of Function and may Promote Recovery of Function Congenital renal insufficiency/failure Posterior Urethral Valves in the Newborn Bilateral Obstruction Congenital renal insufficiency/failure Bilateral Agenesis 2 min 20 min Congenital renal insufficiency/failure Bilateral Dysplasia in the newborn 2 min 4 10 12 CONGENITAL RENAL INSUFFICIENCY/FAILURE Bilateral Dysplasias • Bilateral Dysplasias or Agenesis • No functioning renal parenchyma • No Intervention indicated, no recovery expected MOST COMMON INDICATIONS FOR RENAL SCINTIGRAPHY NEONATE CONGENITAL RENAL INSUFFICIENCY/FAILURE • PERINATAL COMPLICATIONS WORK UP OF SONOGRAPHIC FINDINGS MASSES IN THE ABDOMEN SEARCH FOR AND EVALUATION OF CONGENITAL UT ANOMALIES Diagnosis-Prognosis-Follow up MAG3 -F0 in Perinatal Renal Disorders Acute Tubular Necrosis Renovascular Hypertension Adrenal Hemorrhage Normal size Solid kidneys, Preservation of Flow and Cortical Uptake; Delayed Drainage; High Residual Cortical Activity: Acute Tubular Necrosis: No intervention; Full Recovery Perinatal Renal Insufficiency/Failure: Newborn with Severe Oliguria Diabetic Mother and Difficult, Prolonged Delivery Neonates with hypertension from renal ischemia due to thrombus in the umbilical catheter should not be treated with ACE-Inhibitors Neonatal Hypertension from Aortic Thrombus Around Aortic Catheter Left Infarction Right Ischemia MAG3 -F0 in Neonatal Hypertension from renal ischemia due to thrombus around the umbilical catheter Baseline Renogram ACE Inhibition Renogram This infant should not be treated with ACE-Inhibitors Perinatal Adrenal Hemorrhage MOST COMMON INDICATIONS FOR RENAL SCINTIGRAPHY NEONATE INFANT OR OLDER CHILD CONGENITAL RENAL INSUFFICIENCY/FAILURE PERINATAL COMPLICATIONS • WORK UP OF SONOGRAPHIC FINDINGS • MASSES IN THE ABDOMEN • SEARCH FOR AND EVALUATION OF CONGENITAL UT ANOMALIES Diagnosis-Prognosis-Follow up MAG3 -F0 in Congenital Non-Obstructing Renal Diseases Unilateral Agenesis Hypoplasia Ectopia Horse-shoe kidney Multicystic Kidney Disease Polycystic Kidney Disease Megaureter Agenesis Hypoplasia with contralateral Compensatory Hypertrophy 2 min kc 20 min Ectopic normal kidney (pelvic) Ectopic esp. normal kidneys are missed about 50% by routine Ultrasonography but they can very easily be identified by MAG3 -F0, within 2 min after injection Horseshoe Kidney Non-obstructed Multicystic Dysplastic Kidney Multicystic Dysplastic Kidney Multicystic Dysplastic Kidney Polycystic Kidney Disease Autosomal Recessive 2 min 4 12 14 Mild infantile type 18 20 Polycystic Kidney Disease Children: Autosomal Recessive Other congenital diseases (Scan: Large kidneys with DPD) Adults: Autosomal Dominant (Scan: Large kidneys with evidence of multiple cysts) Polycystic Kidney Disease Autosomal Dominant (usually in adults) Cysts Normal drainage MEGAURETER without OBSTRUCTION Use of Bladder Catheterization FOLLOW UP Idiopathic NEWBORN Megaureter 2 min 2 min 20 min Delayed NEWBORN FOLLOW UP NEUROGENIC BLADDER MAG3 -F0 in Congenital Renal Obstruction Anatomic Uretero-Pelvic Junction Obstruction Uretero-Vesical Junction Obstruction Posterior Urethral Valves Functional Vesico-Ureteral Reflux OBSTRUCTION Can we prevent the loss? Neonate 5 year old Proximal Obstruction ( Uretero-Pelvic Junction ) 2min 4 10 12 25min 18 20 Distal Obstruction ( Uretero-Vesical Junction ) 2min 4 10 12 kc 18 20 25min Pelvic Ectopic Obstructed Kidney (UPJO) 2 min 4 min 6 min Contrast enhanced images Findings: Early Defect and Late Retention Left Upper Pole Defect Urinary Bladder Diagnosis: Duplication with Upper Moiety Obstruction, Ectopic Ureter, and Ureterocele Newborn with abnormal prenatal ultrasound Findings: Early Defect and Late Retention Left Upper Pole Defect Urinary Bladder Diagnosis: Duplication with Upper Moiety Obstruction, Ectopic Ureter, and Ureterocele One and ½ month old with abnormal ultrasound referred from outside for evaluation Duplication with Ectopic Ureter Ureterocele and Upper Moiety Obstruction 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 Right Pelvic Retention but Normal Drainage of the Cortex and Downsloping Renogram Prognosis: High probability for Spontaneous Compensation; Surgery Not Needed SRF 45/55 L/R Follow up study shows Improvement of Drainage and Preservation of Renal Function SRF 50/50 L/R Newborn with pelviectasis evaluated for obstruction Newborn A down-sloping MAG3-F0 renography in the neonate predicts 6 mo old Spontaneous Compensation High Pelvic Retention; Abnormal Drainage of the Cortex and Upsloping Renogram: UPJO Prognosis: No probability for Spontaneous Compensation; Surgery is Needed The infant was not operated but was followed up with scintigraphy Follow up study shows Deterioration of Drainage and Loss of Renal Function Newborn with severe pelvicaliectasis evaluated for obstruction Newborn An Up-sloping MAG3-F0 renography in the neonate predicts 1 mo old The need of Surgical Correction A Horizontal Renogram requires follow up studies FOLLOW UP STUDIES Follow Up Studies Horse-shoe kidney non obstructed; newborn and 6 year old Follow Up Effect of Therapy Posterior Urethral Valves Newborn At birth Post Therapy S/P Therapy Posterior Urethral Valves Congenital renal insufficiency/failure Posterior Urethral Valves in the Newborn and F/U post therapy Recent Observations When the dilated collecting system keeps the activity but the CORTEX EMPTIES: there is no functional obstruction (reservoir effect) or there is no obstruction at all MAG3 -F0 in Renal Obstruction: New Findings Traditional concept: To make the Diagnosis of Obstruction you need to Study the Renogram and the Collecting System of the Kidney New Horizons: To make the Diagnosis of Obstruction you better study the behavior of the Renal Parenchyma: If the Parenchyma empties, there is no obstruction! (even when the drainage system is dilated and it does not empty appropriately) Clinical Experience on The Discrepancy between the Parenchyma (Empties appropriately) and the Drainage System (suggests Obstruction) • Different categories of patients with Congenital or Acquired disorders • Frequent finding in patients with chronic problems • Data were presented
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