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 at the 2003 SNM meeting
• Potential problems in patient care if this finding is not recognized (considering surgery etc) Patients with Dilated Collecting System but Physiologic Drainage of the Parenchyma (Cortex)
• Extra-Renal Pelvis • Post-Operatively after Pyeloplasty • Congenital Pelviectasis • Chronic Nephrolithiasis usually after Colics
Characteristics
• The Parenchyma Empties in Normal Sequence but • The Drainage system retains the activity (Pelvi-cali-ectasis) • The Function of the kidney (SRF) does not deteriorate EXTRARENAL PELVIS and OBSTRUCTION
A dilated extra-renal pelvis may not be obstructed
Yet there is retention of urine in the pelvis even after diuretic and an abnormal obstructive kidney renogram
When the cortex empties normally there may not be obstruction and a non-obstructive cortical renogram confirms this
If the patient is asymptomatic no intervention needed EXTRARENAL PELVIS without OBSTRUCTION Newborn
17 month old EXTRARENAL PELVIS without OBSTRUCTION POST-OPERATIVE DILATED PELVIS and OBSTRUCTION
After surgical correction of obstruction a dilated pelvis may persist but there may be no residual obstruction
Yet there is retention of urine in the pelvis after diuretic and an abnormal obstructive kidney renogram
When the cortex empties normally may not be obstruction and a non-obstructive cortical renogram confirms
If the patient is asymptomatic no intervention needed POST-OPERATIVE DILATED PELVIS without OBSTRUCTION
A dilated pelvis after Pyeloplasty with an abnormal obstructive kidney renogram may not be obstructed when the cortex empties normally DILATED PELVIS s/p PYELOPLASTY without OBSTRUCTION PRE-OPERATIVE
POST-OPERATIVE NON-OBSTRUCTED CORTEX in the presence of dilated, abnormal collecting system The Non-Obstructed Cortex Empties
The appearance of the Renogram depends on the Appropriate Placement of the Regions Of Interest (ROI) by the Technologist Obstructed v/s Non-obstructed Parenchyma in the presence of dilated, abnormal collecting system Case No 1 Non-obstructed Parenchyma v/s Obstructed in the presence of dilated, abnormal collecting system: non-obstructed Parenchyma Empties, obstructed does not Case No 1
In this case the left cortex empties but the right does not empty IF THE CORTEX EMPTIES, THERE IS NO OBSTRUCTION In the presence of a dilated, abnormal collecting system The Non-Obstructed Cortex Empties The Obstructed Cortex does not empty
Case No 1
left right left right
min min
Left: Non-obstructed; Right: Obstructed Non-obstructed Parenchyma in the presence of dilated, abnormal collecting system Does the renogram of the Non-Obstructed Parenchyma Empty?
If the ROI is placed Appropriately The Renogram is correct, that is Normal:
Case No 1 Non-obstructed Parenchyma in the presence of dilated, abnormal collecting system Does the renogram of the Non-Obstructed Parenchyma Empty?
If the ROI is placed inappropriately (too deeply) The Renogram is Wrong, that is Abnormal:
Case No 1 Congenital Pelviectasis and Mega-ureter 11/3/2004 First Study
Case No 2 11/3/2004
The cortex of the left kidney appears to empty properly Congenital Pelviectasis and Mega-ureter 11/3/2004 First Study Case No 2 11/3/2004
The cortex of the left kidney appears to empty properly: Wait and See Congenital Pelviectasis and Mega-ureter 9/9/2005 Follow up Study Case No 2 9/9/2005
Slight Improvement in renograms, Split Renal Function Stable EXTRARENAL PELVIS without OBSTRUCTION Newborn
17 month old Extra-renal Pelvis with Normally Emptying Cortex
Asymptomatic 55 yo man with incidental finding of “hydronephrosis” on CT Extrarenal Pelvis S/p Endo-Pyeloplasty without Obstruction
Case No 7 CORRECT WAY OF READING
INVESTIGATE BOTH THE PARENCHYMA AND THE DRAINAGE SYSTEM 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