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 Introduction George N. Sfakianakis MD Professor of Radiology and Pediatrics Director Division of Nuclear Medicine
HISTORY Rational Science and Medicine When the whole thing started?
HIPPOCRATES Father of Rational Medicine HISTORY DEMOCRITOS Father of the Atomic Theory of the Matter EPICUROS Father of Nuclear Science and Nuclear Medicine The Miracle of the 5th Century BC
HISTORY Modern Atomic Theory John Dalton 1880 Discovery of Natural and Artificial Radioactivity Henry Beckerel 1896 Marie Curie 1897
Wilhelm C. Roentgen 1895 HISTORY Dmitry I. Mendeleyev 1896 Georg de Hevesy 1913 Discovery of X-Rays 1895 The Periodic Table of the Elements The first use of radioisotopes in humans The Tracer Principle
Benedict Cassen HISTORY Hal Anger Ernest O. Lawrence Cyclotron Rectilinear Scanner 1950 Gamma Camera 1957 Ter-Pogossian PET Scanner
RENAL SCINTIGRAPHY INTRODUCTION
Did you ever want to have one Fast and Easy Protocol for Scintirenography? The same for All Indications (Parenchymal and Drainage) Irrespective of the Age of the patient, the degree of impairment of the Renal Function, the general clinical Condition of the patient And obtain also information about Prognosis Absolutely Safely and Reproducibly This is the MAG 3 -F 0 Protocol
Sophisticated Protocols for Renal Scintigraphy We call Sophisticated Renal Scintigraphy the Traditional Methods with Bladder Catheterization and injection of Diuretic 20-30 + min post radiopharmaceutical These old traditional methods were inspired before U/S, CT, MRI, were proposed by the experts in the field of renal imaging at the time, endorsed by the Societies SNM, Pedi Fetal etc - but not revisited and still followed by many laboratories (due to lack of communication) We believe these protocols serve the exceptions rather than the patient population we currently evaluate in Nuclear Medicine
Problems with the Sophisticated Protocols for Renal Scintigraphy Patient Preparation is Painful and potentially Dangerous (Bladder Catheterization and IV hydration) Studies are Too Lengthy (40min-60min) The radiation Exposure to the gonads is higher Diagnosis for Cortical problems is not obtained Prognosis is not usually possible As a result renal scintigraphy has always been and still is underutilized
Sophisticated Protocols for Renal Scintigraphy Father: Better operate on my child than ask for a nuclear study (Testimony of Dr Ricardo Gonzalez, Pedi-Urologist) Those who practice pediatric nuclear medicine had these concerns since the seventies and eighties
Current Status of Renal Scintigraphy Variety and complexity of Radiopharmaceuticals and Protocols Referring Physicians (urologists, nephrologists, internists, surgeons), Radio-Pharmacists, Technologists, and involved Administrators along with Nuclear Medicine Practitioners and Radiologists are all confused by the large number of Radiopharmaceuticals and the great variety and complexity of the different Protocols for Renal Scintirenography, which is in general, underutilized. We addressed this long ago and we have identified and applied The BEST Radiopharmaceutical and a single EASY protocol
THE NEED FOR A NEW PROTOCOL There has always been a need for a single, easy, fast and simple protocol patient and technologist friendly to provide information about drainage and also about focal and global renal cortical function Recent improvements in patient care, other methods (US) and economic issues had made this protocol mandatory
Recent Improvements in Other Imaging Modalities which threaten the use of the Sophisticated Scintigraphy Ultrasound Improved Resolution - Doppler Three Dimensional Contrast Agents Computed Tomography Spiral CT Dynamic Studies with Contrast CT-Angiography Magnetic Resonance Imaging GFR Contrast Dynamic Studies MR-Angiography MR-Renography
W. K. Rohrschneider Methods : Combined Static-Dynamic MR Urography Post processing
There has always been a need for an easy and simple protocol But recent improvements in patient care and economic issues have made this need mandatory
THE FAST PROTOCOL: It began at OSU and continued at UM first as Hippuran-F 3 and when MAG 3 became available (1988) as 99m Tc-MAG 3 -F 0
THE UNIVERSITY OF MIAMI APPROACH RENAL SCINTIRENOGRAPHY IN THE 21 st CENTURY 99m Tc- MAG 3 with zero time injection of Furosemide (MAG 3 -F 0 ) A Fast and Easy Protocol, for drainage and cortex One for All Indications and all ages
RENAL SCINTIGRAPHY AT UM/JMMC: (MAG3-F0) Method applied the last 18 years: One only Protocol: Simple, Easy and Fast (22 min) : -No Bladder Catheterization / Oral Hydration -One Injection (MAG3 and Diuretic simultaneously = F0) -The Same Protocol for All Indications (APN) since 1994 -It serves the vast Majority of Cases (not the Exceptions) Education of Referring and User Physicians Participation in Clinical/Educational Activities of Clinicians Research and Publications with Clinicians Results: 7-15 renal studies per day the last few years
BASIC PRINCIPLE FOR THE NEW PROTOCOL: (MAG3-F0) Furosemide given IV: Diuretic Effect begins between 4-5 min Maximum Effect at 9 min
PRECIOUS INFORMATION from MAG 3 -F 0 Morphologic and Functional Information(regional/global) in All Ages and Functional States including Renal Failure For Congenital or Acquired diseases including Transplants Essential for Diagnosis, Prognosis and Follow-Up about: Renal Blood Flow: First pass study images, Flow Velocity Index quantified Renal Parenchymal (cortical) function: Focal Disorders visualized, Global Function quantified Intra/Extra-Renal Drainage System: Morphologic changes visualized, Drainage quantified MAG 3 -F 0 is Technically Easy/ Safe/Acceptable/Affordable
CURRENT CLINICAL STATUS of 99m Tc-MAG 3 -F 0 Advantages of the 99m Tc-MAG 3 -F 0 protocol as compared to Old: Easy, Fast, one for All Indications, All Ages, All Kidney Disorders At the UM we perform 7-15 renal scintigraphic studies per day Disadvantages of Renal Scintigraphy in general experienced also with the MAG 3 -F 0 protocol : Biologic Limitations (tumors, stones, calcifications, resolution) Unfamiliarity among referring and user doctors (elsewhere) Correlative Imaging Modalities successful(u/sound, CT, MRI)
TO OBTAIN BEST RESULTS WITH THE FAST PROTOCOL WE NEED TO EMPLOY THE BEST RADIOPHARMACEUTICAL Which one is the best? WITH THE BEST PROTOCOL Which one is the best?
RENAL RADIOPHARMACEUTICALS 99m Tc-MAG 3 :.Tubular Excretion (EE = 60%) 123/131 I-o-Hippurate:..GF and TE (EE = 80%) Global Dynamic Tubular Function Imaging Dynamic ERPF Imaging 99m Tc-DTPA:.Glomerular Filtration (EE = 20%) Dynamic Imaging of GFR 99m Tc-DMSA: Cortical Fixation(GF and reabsorption)(ee = 5%) Parenchymal Function Imaging 99m Tc-GH:..Combined GF and Cortical Fixation (EE = 20%) Dynamic GF and Parenchymal Imaging
Comparison Between 99m Tc-MAG 3 and 123/131 I-o-Hippurate
Misunderstanding Ye have heard that it was said by them of old time: DTPA is a good imaging agent for kidneys But we say unto you MAG 3 is a much better agent for renal scintigraphy
ADVANTAGES of MAG 3 for RENAL SCINTIGRAPHY High Renal Extraction Efficiency 60% Fast parenchymal accumulation Fast background clearance Effective Parenchymal Imaging (early/late e.g.: APN) Accurate evaluation of Intra/Extra Renal Drainage Small Distribution Space Steep (sensitive) Renograms Technetium-99m-Chemical Labeling High dose, Good statistics, Low radiation exposure Safe (experience 18 years)
COMPARISON of MAG 3 with DTPA MAG3 DTPA Congenital Anomalies (Cross Ectopia)
MAG 3 COMPARISON TO DTPA MAG 3 DTPA 1) KIDNEY HANDLING TUBULAR GLOMERULAR
MAG 3 COMPARISON TO DTPA MAG 3 DTPA 1) FUNCTION TUBULAR GLOMERULAR Visualizes Kidney when no GF (ATN, Total obstruction, toxicity): Successful Visualizes Focal Lesions (APN, dysfunction etc): Hot Spot No visualization Cold Spot(?)
MAG 3 COMPARISON TO DTPA MAG 3 DTPA 2) EXTRACTION EFFICIENCY 60% 20%
MAG 3 COMPARISON TO DTPA MAG 3 DTPA 2) EXTRACTION EFFICIENCY 60% 20% Parenchymal Evaluation (Rejection, Nephrotic, Nephritic etc) Successful Mediocre Study of Drainage (Diuretic Renography etc): Successful Mediocre Patient Radiation (Radiation exposure of the patient): Lower Higher
MAG 3 COMPARISON TO DTPA MAG 3 DTPA 1) FUNCTION TUBULAR GLOMERULAR Visualize Kidney when no GF (ATN, Total obstruction, toxicity): Successful No visualization Visualize Focal Lesions (APN, dysfunction etc): Hot Spot Cold Spot(?) 2) EXTRACTION EFFICIENCY 60% 20% Parenchymal Evaluation (Rejection, Nephrotic, Nephritic etc) Successful Mediocre Study of Drainage (Diuretic Renography etc): Successful Mediocre Patient Radiation (Radiation exposure of the patient): Lower Higher
THE BEST RADIOPHARMACEUTICAL Finally it was Recognized to be 99m Tc - MAG 3 THE PROTOCOL Which one is the best?
OUR EXPERIENCE PROVES THAT THE BEST PROTOCOL IS 99m Tc- MAG 3 with zero time injection of Furosemide: MAG 3 -F 0
THE BEST RADIOPHARMACEUTICAL Selected to be 99m Tc - MAG 3 THE PROTOCOL 99m Tc- MAG 3 with zero time injection of Furosemide: MAG 3 -F 0 This protocol addresses the majority of cases (>99%)
MAG3-F0 Protocol Next Summer: Day Sessions in Greece
MAG3-F0 Protocol Next summer: Night Sessions in Greece
THE FAST PROTOCOL: It began at OSU and continued at UM first as Hippuran-F 3 and when MAG 3 became available (1988) as 99m Tc-MAG 3 -F 0
RENAL STUDIES: PROTOCOL AT UM/JMH 99m Tc-MAG 3 -F 0 (or MAG 3 -F 0 ) No difficult Patient Preparation is needed No Sedation (only restriction of motion) Hydration 5-10 ml/kg water orally or iv at 30 min No Bladder Catheterization (except in selected cases) Study either supine or upright
PROTOCOL FOR MAG 3 - F 0 PATIENT PREPARATION Easy (only restriction, oral hydration, no bladder cath.) DYNAMIC STUDY (iv 1-10 mci MAG 3 + 40-80 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
RENAL SCINTIGRAPHY AT UM/JMMC: (MAG3-F0) Method applied the last 18 years: A. DYNAMIC STUDY Injection iv 1-10 mci MAG 3 + 40-80 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 25-30 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
RENAL SCINTIGRAPHY AT UM/JMMC: (MAG3-F0) Method applied the last 18 years: FOR NATIVE KIDNEY STUDIES FOR RENAL TRANSPLANT STUDIES
PROTOCOL #2 FOR MAG 3 - F 0 B. TOMOGRAPHIC (SPECT) STUDY (evaluates Cortical Anatomy in 3D, Ectopias, Split RF) Injection iv 2-20 mci MAG 3 No Lasix needed Acquisition of the study 4min
QUANTIFICATION TIME ACTIVITY GRAPHS (flow/function/drainage) SPLIT RENAL FUNCTION GLOBAL RENAL FUNCTION (CLEARANCE)
TIME ACTIVITY GRAPHS OF SCINTIGRAPHY a) Renal Blood Flow Graph 1 sec/point for 30-60 sec First Pass Renal Perfusion Activity b) Renogram (Cortical or Kidney including Pelvis) 30 sec/point for 24 min Balance of feed in-uptake-discharge activity
REGIONS OF INTEREST: NATIVE KIDN. AND TRANSPLANTS for flow for kidney for cortex for kidneys for cortex background 2 background 3
TIME ACTIVITY GRAPHS: BLOOD FLOW GRAPHS
TIME ACTIVITY GRAPHS: KIDNEY GRAPHS and CORTICAL GRAPHS
EVALUATION OF TIME/ACTIVITY GRAPHS a) Visual Evaluation in most cases b) Simple Indices in all cases i. Flow Velocity Index ii. OCA (2.5/20min), Tpeak, T-1/2, RCA (20/peak) c) Sophisticated Mathematical Analysis i. Mean Transit Time (Flow) ii. Deconvolution Analysis (Renogram) d) Computer Automation i. Neural Networks ii. Artificial Intelligence
FLOW GRAPHS FLOW VELOCITY INDEX NORMAL GRAPHS FLOW VELOCITY INDEX = 0.9
RENOGRAMS RCA AND OCA