PAEDIATRIC RENAL IMAGING. Dr A Brink

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1 PAEDIATRIC RENAL IMAGING Dr A Brink

2 Causes of hydronephrosis includes: Pelvi-ureteric obstruction Vesico-ureteric reflux Vesico-ureteric obstruction Posterior uretral valves Duplex kidneys

3 Radiopharmaceutical of choice: 99m Tc-MAG3 (mercaptoacetyl triglycine): Taken up in the kidney via tubular secretion (98%) and glomerular filtration (2%). 90% protein bound. 40 % of MAG3 in blood is taken up into the kidneys every time the blood circulates through the kidneys. 70% of the MAG3 is in the urine 30 minutes after injection.

4 What do you need to get a good quality MAG 3 scan?

5 What do you need to get a good quality MAG 3 scan? A WORKING KIDNEY! Difficult and sometimes impossible to interpret if there is CRF.

6 MAG3 renogram = Dynamic study

7 What is the most important information supplied by the MAG3 renogram?

8 What is the most important information supplied by the MAG3 renogram? The differential renal function. The differential renal function. The differential renal function. The differential renal function. The differential renal function. The differential renal function. The differential renal function. The differential renal function.

9 What is the most important information supplied by the MAG3 renogram? Differential renal function only tells us how the kidneys work in relation with each other. It does not give us information on the global renal function. If you want to calculate the absolute differential renal function, adding a GFR is imperative. Absolute GFR is valuable in cases with bilateral disease.

10 How is Differential Renal Function (DRF) calculated? MAG3 cannot move through the nephron in under 2,5 minutes.

11 How is Differential Renal Function (DRF) calculated? MAG3 cannot move through the nephron in under 2,5 minutes. DRF is calculated on the 1-2 minute image. Given adequate time for mixing and uptake. None of the counts (radioactivity) can be in the collecting system jet.

12 How is DRF calculated? Two accepted methods, Integral method and Rutland Patlak plot. Basic principle:

13 How is DRF calculated: We draw regions of interest (ROI) to tell the computer where the kidneys are. These are not allowed to cut the kidneys. Backgound ROI s More than one method, C- shaped and peri-renal most acceptable. Background ROI s Must stay inside the patient!

14 So what does DRF measure?

15 So what does DRF measure? We are comparing the two kidneys with each other. Normal range is:45-55% It does not give an indication of how well the kidneys work as a unit. You can have 50/50% DRF and renal failure. Problematic if there is bilateral disease, then it is useful to add a validated GFR measurement to calculate absolute DRF.

16 The Stages of the renogram Four stages : Perfusion Uptake Excretion Clearance

17 The curve

18 The curve

19 Lasix response Lasix response = Non obstructed system

20 The hydronephrosis dilemma

21 Causes of absent lasix response Dehydration Large collecting system Full bladder Renal insufficiency Renal immaturity Inadequate diuretic dose

22 Indications for Intervention 1. Infections/Complications. 2. Fall in differential renal function. 3. Increasing AP pelvis (relative indication).

23 Background Prenatal hydronephrosis is found in approximately 0.25% of pregnancies(1). There is spontaneous resolution in: 50% of cases with mild 15% with moderate and 0% with severe hydronephrosis(2). 1.Helin I, Person P.H. Prenatal diagnosis of urinary tract abnormalities by ultrasound. Pediatrics, 78:879, Feldman, D.M. et al: Evaluation and follow-up of fetal hydronephrosis. J Ultrasound Med, 20: 1065,2001.

24 DRF 50/50%. AP pelvis Calyceal dilatation Baseline MAG3 at Follow-up MAG3 at < 20 mm Seldom marked 3/12 9/ mm Not marked 9/52 6/12-9/ mm Marked 6/52 3/12 6/ mm Not marked 6/52 6/52 3/ mm Marked 3/52 3/52-6/52 > 40 mm uncommon at 50/50% DRF

25 IMAGING IN HYDRONEPHROSIS Ultrasound studies are booked between two MAG3 studies. If the ultrasound results are of concern the MAG3 study is moved forward.

26 DRF 30/70% DRF 30/70% follow-up MAG3 and ultrasound studies are done earlier because the one kidney is already compromised As with DRF 50/50% the MAG3 renogram is moved forward if the ultrasound results are of concern.

27 DRF 15/85% - 20/80% The follow-up MAG3 is done 2/52-4/52 after initial study. Consider doing a MCUG here. These patients are candidates for nephrostomy early surgery early stent.

28 DRF of affected kidney < 10%. Probably not salvageable, surgery often technically very difficult. Probably not worth saving.

29 Standard deviation Reproducibility: PI SI SRP HI HRP II IRP Percentile

30 Watch out if...

31 Vesico-ureteric reflux

32 VUR case study pt PG

33 VUR case study Pt PG

34 VUR case study Pt PG: indirect cystogram

35

36

37 Bilateral hydronephrosis

38

39 F A June minute image

40 F A June 2008

41 Fazili A 10 June 2008

42 F A June 2008

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