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Proceduresof Choice in Renal Nuclear Medicine

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Proceduresof Choice in Renal Nuclear Medicine Proceduresof Choice in Renal Nuclear Medicine M. Donald Blaufox Department ofNuclear Medicine, Albert Einstein College ofMedicine/Montefiore Medical Center, Bronx, New York radionuclide method for measuring residual urine, which The uronephrologicapplicationsof nuclear medicine have was described more than 20 years ago, has not achieved reached a stage of maturity where procedures of choice for general use and may now be largely obsolete. Testicular manyspecificclinicalproblemscan be identified.This review imaging is established in genitourinary imaging while the attempts to achieve this aim as objectively as possible. It application of radionuclides to studies of patients with must be emphasizedthat the opinionsexpressedhere are impotence and related diseases is rapidly moving toward those of the author and in many areas there may be a lack of clinical practice and will likely expand this area of use in consensus. the future. J NuclMed 1991;32:1301—1309 The specific pathologic conditions in which nuclear medicine may play a role are listed in Table 2. In reviewing procedures of my choice in renal nuclear medicine, it is necessary also to evaluate these procedures he most important concept in studying the kidney is in relation to radiographic and other diagnostic imaging a recognition of the intimate relationship between struc procedures. The complementary modalities to be consid ture and function. Although procedures which are primar ered are ultrasound, urography, angiography, and corn ily functional and procedures dependent on imaging are puted tomography (CT). At this time, there are few data discussed separately here, no renal study can be evaluated that would support the utilization of magnetic resonance properly without considering its physiologic basis. Table 1 imaging (MRI) in the routine clinical evaluation of the lists the major radionuclide procedures available in uro kidneys and urinary tract. This area ofapplication of MRI nephrology. has been a great disappointment so far, but continues to Among the clearance methods, the continuous infusion be an area of active investigation. technique has been and continues to be a major method for investigational studies where accurate and precise RADIOPHARMACEUTICALSFOR RENAL STUDIES measurements of renal function are needed. The use of The radiopharmaceuticals that have been used for kid continuous infusion clearance in clinical practice is limited ney studies are shown in Figure 1. and will not be discussed here. The single injection clear ance methods offer the great advantages ofsimplicity, ease Glomerular Filtration Rate of performance, low radiation dose, and reasonable accu The radionuclide agent of choice for an extremely ac racy. curate measurement of the glomerular filtration rate Radiorenography has evolved into a complex technique. (GFR) is 51Cr-EDTA(1). This agent is not available in the Captopril renography is being used with increasing fre U.S., but it is widely used in Europe. The clearance of 51C- quency while exercise stress renography may prove to be EDTA is virtually identical with the clearance of inulin, of value in the future. Among the pharmaceuticals for therefore, it is a true GFR marker. In the U.S., 1311 renal imaging, 99mTc..glucoheptonate and @mTc@DMSAiothalamate has been used in its place. Technetium-99m- have very different mechanisms of renal handling than DTPA has a clearance rate approximately 5% less than 99mTcDTpA (excreted by glomerular filtration), and that of inulin (2), which usually is an acceptable error in 99mTcMAG and ‘311-hippuran(excreted primarily by tu clinical practice. The error of serum creatinine is in the bular secretion). Technetium-99m-MAG3 has been ap range of 10% or 15% in estimating GFR and may be proved recently by the FDA and is available for routine greater in renal failure. Technetium-99m-DTPA yields an applications, although pediatric use of this agent has not estimate of the GFR within 5% of the true GFR. It is yet received approval. inexpensive, has a low radiation dose, and, most impor The radionuclide cystogram has achieved widespread tantly, it can be usedfor renal imaging, making it the GFR application in the evaluation of ureterovesical reflux. The agent ofchoice overall in clinicalnuclear medicine practice. TubularSecretion Received Nov. 14, 1990; revision accepted Mar. 27, 1991. For reprintsContact:M.DonaldBlaufox,MD,PhD,AlbertEinsteinCollege Iodine-131-hippuran is currently the agent of choicefor of Medicine, 1300 Morris Park Ave., Bronx, New York 10461. estimating effective renalplasmafiow (ERPF). Iodine-123- Procedure Choices in Renal Nuclear Medicine •Blaufox 1301 TABLE I TUSULARRE8ORpflCH ..@ .. OLOMERULARFILTRAT1ON @ Lkonephrologic Procedures in Nudear Medicine @To@schniS@• . I “@“c@ @ “•,_.‘@‘I4S8A ___ 1. ClearanceMethods 5. RadiOnUclidecystogram I I c __J“cl'EDyA A. Continuousinfusion A. Residualurine \ — “0LfrOTPA B. Singleinjection B. Ureterovesicalreflux I I @To@OT@ C. Simplifiedsingleinjec 6. Scintiphotography I @@4-OA@@s tion A. lndMdualrenalfunction ri D. Invivocamera tech 1. 131l_,lssl@hippuran CORTEX niques 2. @“Tc-DTPA Tueu@ReEcRE@Ow. 2. Radioimmunoassay 3. @Tc-MAG3 EFFECTRERENALPLAMAFLOW 3H.‘@C@PAH @ A. Angiotensin B. Individualrenalmass IR,@ B. ReninactMty 1. @Tc-DMSA C. 2. @“Tc-glucoheptonate 3. Radiorenography C. Perfusionimaging A. @“1c-DTPA 1. Anylow-dose @rcagent B. ‘31―@I-hippuran D. Morphology Tueu@RRXATmN. C. 1. Renalmassagents MEDULLA @MOR@OLOOv D. Miscellaneous 7. Renal blood flow 4. Body spaces 8. Genitalimaging A. Penilebloodflow B. Testicularperfusion hippuran has a lower radiation dose, and so it is theoreti FIGURE1. Graphicdepictionof the areasof the nephron cally preferable to 1311,but because ofcost limitations and where various radiopharmaceuticalsare handled. Those phar a short shelf life, the 1311agent is the most practical for maceuticalsthat areconsideredto beagentsof choiceareshown measuring ERPF. Technetium-99m-MAG3, which has inbold. only been available for a relatively brief time in the U.S., may assume a major role in evaluating tubular secretion. MAG3 is significantly different from hippuran in that Static Imaging Agents MAG3 apparently clears at a rate lower than ‘31I-hippuran Technetium-99m-DMSA and @mTc@glucoheptonateare (about 80%) because it is not filtered by the glomerulus the two major agents available for renal parenchymal (4). Although it has lower clearance values, MAG3 is taken imaging. These two radiopharmaceuticals are very differ up in very high quantities, gives excellent renal images, ent. A significant portion ofglucoheptonate is ifitered (5), and has moved rapidly into routine practice. The small so that in patients with urinary tract obstruction, the difference in excretion characteristics may be of value in accumulation of glucoheptonate in the collecting system some situations where it is desirable to evaluate pure can present a problem in interpreting parenchymal images. tubular secretion. Hepatic excretion ofMAG3 is a problem In patients without urinary tract obstruction, the filtered that may interfere with its use in single injection clearances component is not a problem and it can be advantageous at low levels of renal function. Clearance techniques that in providing additional information about the collecting include urine collection avoid this problem. system. Technetium-99m-DMSA is handled by a very different TABLE2 excretory mechanism (6). Glucoheptonate shares the en NuclearMedicinein GenitounnaryDisease zyme system for para-amino-hippuric acid and 131I-hip Acute renal failure puran in the proximal tubules, while 99mTcDM5A is cx Chronicrenalfailure creted by a different process. It is concentrated to a greater Con@ anomahes extent (about 40% ofit is accumulated in the kidneys) and Epididymitis as a result 99mTcDM5A delivers a much higher radiation Impotence dose (per MCi administered) to the kidney than 99mTc@ MassLesions Pyelonephritis glucoheptonate. If a renal perfusion study is needed in Quantitationof renalfunction conjunction with a static imaging study, @mTc@glucohep RenalperfusionabnOrmalities tonate is suitable because of the lower radiation dose. Renaltrauma Technetium-99m-DMSA should not be used for flow stud Renovascularhypertension ies, but it is an ideal agent for extremely detailed renal Residualurine Testiculartorsion cortical images. The best way to minimize radiation dose Transplantation and perform a flow study in patients in whom perfusion Ureteralvesicalreflux imaging is needed in concert with static imaging is to do a Urinarytractobstruction flow study with @mTc@DTPAfollowedby a static study with Varicocoele 99mTcglucoheptonate, or if very fine resolution is needed, I 302 TheJournalof NuclearMedicine•Vol.32 •No.6 •June1991 followed by 99mTcDMSA Quantitative separated renal ERPF: in vitro 1 sample method ( fl ) vs. in vitro 2 sample method (I) function studies may be performed with DMSA. Many 800 centers use a single dose of glucoheptonate for the perfu @ 700 sion and imaging study. A number of centers use gluco @ heptonate instead of DMSA for quantitative imaging. 600 • • •••• • S . • Gallium may be considered as a renal agent when used @5oo. S @ in studying pyelonephritis or renal abcess. Monoclonal 400 antibodies and indium-labeled white cells have not proved practical for renal imaging and are not discussed here, E @-.-—-.--@ y(fl)—O.850X(I)-73 @ although they are still being actively investigated. 200 n-41 @ CLEARANCEMETHODS I
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