RENAL SCINTIGRAPHY IN THE 21 st CENTURY

Transcription

1 RENAL SCINTIGRAPHY IN THE 21 st CENTURY 99m Tc- MAG 3 with zero time injection of Furosemide (MAG 3 -F 0 ) : A Fast and Easy Protocol, One for All Indications Clinical Experience Congenital Disorders

2 PROTOCOL FOR MAG 3 - F 0 PATIENT PREPARATION Easy (only restriction, oral hydration, no bladder cath.) DYNAMIC STUDY (iv 1-10 mci MAG mg LASIX) Simultaneous injection of Furosemide: MAG 3 -F 0 Duration of the study 25 min TOMOGRAPHY-SPECT (20 mci MAG 3 ) No diuretic needed Duration of the study 4 min

3 RENAL SCINTIGRAPHY AT UM/JMMC: (MAG3-F0) Method applied the last 18 years: FOR NATIVE KIDNEY STUDIES FOR RENAL TRANSPLANT STUDIES

4 RENAL SCINTIGRAPHY AT UM/JMMC: (MAG3-F0) Method applied the last 18 years: A. DYNAMIC STUDY Injection iv 1-10 mci MAG mg LASIX (Furosemide) Simultaneous Injection of MAG3 and Lasix = F 0 ACQUISITION: FLOW: FUNCTION: POST VOID DELAYED 1 min ( 1 frame per 1 sec) 22 min ( 1 frame per 30 sec) 2 min static image (at min) 2 min static images (at 1 hr) GROUPING IMAGES : GRAPH GENERATION: -FLOW: in 3 sec images -FUNCTION: in 2 min images -FLOW/FUNCTION, KIDNEY/CORTEX

5 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

6 MAG 3 -F 0 PROTOCOL Misconception You cannot image the kidneys of a newborn You need to catheterize the urinary bladder to exclude obstruction Facts MAG 3 -F 0 works in the Newborn Infant You do not need to catheterize the urinary bladder

7 Typical NORMAL MAG 3 -F 0 in a NEWBORN Indication: Evaluate Pelviectasis found by Ultrasound Normal study; Slight Immaturity, Bladder empties

8 Typical NORMAL MAG 3 -F 0 in a NEWBORN Indication: Evaluate Pelviectasis found by Ultrasound Normal study; Slight Immaturity, Bladder does not empty

9 MAG 3 -F 0 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)

10 Normal MAG 3 -F 0 in an ADULT Indication: Renal Colic

11 INDICATIONS FOR MAG 3 -F 0 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

12 CONGENITAL URINARY TRACT ANOMALIES MAG 3 -F 0 Dynamic Studies Diagnosis-Prognosis-Follow up

13 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

14 MAG 3 -F 0 in Congenital Renal Insufficiency or Failure Posterior Urethral Valves Bilateral Agenesis Bilateral Dysplasia

15 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

16 Congenital renal insufficiency/failure Posterior Urethral Valves in the Newborn Bilateral Obstruction

17 Congenital renal insufficiency/failure Bilateral Agenesis 2 min 20 min

18 Congenital renal insufficiency/failure Bilateral Dysplasia in the newborn 2 min

19 CONGENITAL RENAL INSUFFICIENCY/FAILURE Bilateral Dysplasias Bilateral Dysplasias or Agenesis No functioning renal parenchyma No Intervention indicated, no recovery expected

20 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

21 MAG 3 -F 0 in Perinatal Renal Disorders Acute Tubular Necrosis Renovascular Hypertension Adrenal Hemorrhage

22 Perinatal Renal Insufficiency/Failure: Newborn with Severe Oliguria Diabetic Mother and Difficult, Prolonged Delivery Normal size Solid kidneys, Preservation of Flow and Cortical Uptake; Delayed Drainage; High Residual Cortical Activity: Acute Tubular Necrosis: No intervention; Full Recovery

23 Neonates with hypertension from renal ischemia due to thrombus in the umbilical catheter should not be treated with ACE-Inhibitors

24 Neonatal Hypertension from Aortic Thrombus Around Aortic Catheter Left Infarction Right Ischemia

25 MAG 3 -F 0 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

26 Perinatal Adrenal Hemorrhage

27 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

28 MAG 3 -F 0 in Congenital Non-Obstructing Renal Diseases Unilateral Agenesis Hypoplasia Ectopia Horse-shoe kidney Multicystic Kidney Disease Polycystic Kidney Disease Megaureter

29 Agenesis

30 Hypoplasia with contralateral Compensatory Hypertrophy 2 min kc 20 min

31 Ectopic normal kidney (pelvic) Ectopic esp. normal kidneys are missed about 50% by routine Ultrasonography but they can very easily be identified by MAG 3 -F 0, within 2 min after injection

32 Horseshoe Kidney Non-obstructed

33 Multicystic Dysplastic Kidney

34 Multicystic Dysplastic Kidney

35 Multicystic Dysplastic Kidney

36 Polycystic Kidney Disease Autosomal Recessive min Mild infantile type

37 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)

38 Polycystic Kidney Disease Autosomal Dominant (usually in adults) Cysts Normal drainage

39 MEGAURETER without OBSTRUCTION Use of Bladder Catheterization

40 Idiopathic Megaureter NEWBORN FOLLOW UP 2 min 2 min 20 min Delayed NEWBORN FOLLOW UP

41 NEUROGENIC BLADDER

42 MAG 3 -F 0 in Congenital Renal Obstruction Anatomic Uretero-Pelvic Junction Obstruction Uretero-Vesical Junction Obstruction Posterior Urethral Valves Functional Vesico-Ureteral Reflux

43 OBSTRUCTION Can we prevent the loss? Neonate 5 year old

44 Proximal Obstruction ( Uretero-Pelvic Junction ) 2min min 18 20

45 Distal Obstruction ( Uretero-Vesical Junction ) 2min kc min

46 Pelvic Ectopic Obstructed Kidney (UPJO) 2 min 4 min 6 min Contrast enhanced images

47 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

48 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

49 Duplication with Ectopic Ureter Ureterocele and Upper Moiety Obstruction

50 THE VALUE OF MAG 3 -F 0 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

51 Right Pelvic Retention but Normal Drainage of the Cortex and Downsloping Renogram Prognosis: High probability for Spontaneous Compensation; Surgery Not Needed Newborn with pelviectasis evaluated for obstruction SRF 45/55 L/R Follow up study shows Improvement of Drainage and Preservation of Renal Function SRF 50/50 L/R

52 Newborn A down-sloping MAG 3 -F 0 renography in the neonate predicts 6 mo old Spontaneous Compensation

53 High Pelvic Retention; Abnormal Drainage of the Cortex and Upsloping Renogram: UPJO Prognosis: No probability for Spontaneous Compensation; Surgery is Needed Newborn with severe pelvicaliectasis evaluated for obstruction The infant was not operated but was followed up with scintigraphy Follow up study shows Deterioration of Drainage and Loss of Renal Function

54 Newborn An Up-sloping MAG 3 -F 0 renography in the neonate predicts 1 mo old The need of Surgical Correction

55 A Horizontal Renogram requires follow up studies

56 FOLLOW UP STUDIES

57 Follow Up Studies Horse-shoe kidney non obstructed; newborn and 6 year old

58 Follow Up Effect of Therapy At birth Posterior Urethral Valves Newborn Post Therapy S/P Therapy Posterior Urethral Valves

59 Congenital renal insufficiency/failure Posterior Urethral Valves in the Newborn and F/U post therapy

60 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

61 MAG 3 -F 0 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)

62 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)

63 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

64 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

65 EXTRARENAL PELVIS without OBSTRUCTION Newborn 17 month old

66 EXTRARENAL PELVIS without OBSTRUCTION

67 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

68 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

69 DILATED PELVIS s/p PYELOPLASTY without OBSTRUCTION PRE-OPERATIVE POST-OPERATIVE

70 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

71 Obstructed v/s Non-obstructed Parenchyma in the presence of dilated, abnormal collecting system Case No 1

72 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

73 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

74 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

75 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

76 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

77 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

78 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

79 EXTRARENAL PELVIS without OBSTRUCTION Newborn 17 month old

80 Extra-renal Pelvis with Normally Emptying Cortex Asymptomatic 55 yo man with incidental finding of hydronephrosis on CT

81 Case No 7 Extrarenal Pelvis S/p Endo-Pyeloplasty without Obstruction

82 CORRECT WAY OF READING INVESTIGATE BOTH THE PARENCHYMA AND THE DRAINAGE SYSTEM

83 RENAL SCINTIGRAPHY IN THE 21 st CENTURY 99m Tc- MAG 3 with zero time injection of Furosemide (MAG 3 -F 0 ) : A Fast and Easy Protocol, One for All Indications Clinical Experience Congenital Disorders