ASSESSMENT OF RENAL FUNCTION AND DRAINAGE 1

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ASSESSMENT OF RENAL FUNCTION & DRAINAGE: 

ASSESSMENT OF RENAL FUNCTION & DRAINAGE DR K M LAKSHMIPATHY MBBS PGDNM Ph.D Consultant Nuclear Scans, therapy & PET-CT

RENAL FUNCTION: 

RENAL FUNCTION COMMONLY USED MONITORS : Serum creatinine levels and creatinine clearance Plasma clearance of substances such as inulin, these do not provide functional information for each/ individual kidney. RENAL SCINTIGRAPHY IS UNIQUE FOR ASSESSING INDIVIDUAL KIDNEY FUNCTIONS : Differential renal function (DRF) & GFR

RENOGRAM------- RENAL SCAN: 

RENOGRAM ------- RENAL SCAN DRF, .DRF GFR .NO CLEARANCE .NO RENAL CURVES .NO T1/2 .NO DYNAMIC .STATIC

RENOGRAM: 

RENOGRAM

PowerPoint Presentation: 

GF TS TF Tc-99m DTPA >95% Tc-99m MAG3 <5% 95% I-131 OIH 20% 80% Tc-99m GHA 40%-60% 20% Tc-99m DMSA some 60% Semin NM Apr.92 Extract. fraction Clearance Tc-99m DTPA 20% 100-120 ml/min Tc-99m MAG3 40-50% ~ 300 ml/min I-131 OIH ~100% 500-600 ml/min Tc-99mEC 40-50% 250 ML/MIN

Choosing Renal Radiotracers: 

Choosing Renal Radiotracers Perfusion MAG3, DTPA, GHA Morphology DMSA, GHA Obstruction MAG3, DTPA, OIH Relative function All GFR quantitation I-125 iothalamate, Cr-51 EDTA, DTPA ERPF quantitation MAG3, OIH Clin. Question Agent

NORMAL PLAIN STUDY : 

NORMAL PLAIN STUDY

Hydronephrotic left kidney: 

Hydronephrotic left kidney

Function: 

Function

Pre & post lithotrispsy(ESWL): 

Pre & post lithotrispsy ( ESWL ) Plain Radiography, Renography, and 99m Tc-DMSA Renal Scintigraphy Before and After Extracorporeal Shock Wave Lithotripsy for Urolithiasis 1992, Vol. 33, No. 6 , Pages 569-572. Eighteen patients were evaluated before and 5 weeks after the first treatment with extracorporeal shock wave lithotripsy (ESWL) using abdominal plain radiography, 131 I-hippuran probe renography, and 99m T c -dimercaptosuccinic acid scintigraphy.. In no patient did the scintigrams reveal scars. It is concluded that abdominal plain radiography of the urinary tract and probe renography are complementary and sufficient in the monitoring of patients with urolithiasis post ESWL.

Medicine and Biology Vol.7, No 1, 2000 pp. 102 – 10 : 

Medicine and Biology Vol.7 , No 1, 2000 pp. 102 – 10 RADIONUCLIDE EVALUATION OF RENAL FUNCTION IN PATIENTS WITH RENAL STONE TREATED BY EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY The location of the treated stones was renal pelvis in l0 patients, while 3 patients had calyceal stone. Stone size ranged from 6 to21 mm. All patients studied had serum creatinine valueswithin normal limits. Renal stone presence, location andsize were evidenced by plain X-ray, excretory urography and u/s.

Renal Function Response Following Percutaneous Nephrolithotomy in Patients of Renal Stone Disease with Impaired Renal Function: 

Renal Function Response Following Percutaneous Nephrolithotomy in Patients of Renal Stone Disease with Impaired Renal Function This study suggests that no significant change in renal function occurs following PCNL. However, stone removal should be carried out in all patients of urolithiasis expediently, including patients with poor kidney function, in order to stabilize renal function and prevent further renal damage. Indian Journal of Nuclear Medicine, Vol. 17, No. 1, March, 2002

Contrast toxicity: 

Contrast toxicity The absent kidney in renogram: a dramatic reversible consequence of contrast nephrotoxicity superimposed on renal obstruction RT KIDNEY It has been suggested that it is best to allow an interval of at least 2 weeks after IV contrast medium administration to ensure changes are not due to contrast media

DRF: 

DRF

ADVANTAGES OF F+O: 

ADVANTAGES OF F+O

Pre and post pyeloplasty: 

Pre and post pyeloplasty 8-mo-old girl with preoperative diagnosis of left hydronephrosis. J Nucl Med June 1, 2011 vol. 52 no. 6 905-925

32y/f: 

32y /f Rt extra renal pelvis

36Y/M: 

36Y/M PUJ obstruction

PROMINENT PELVIS: 

PROMINENT PELVIS

ALTERNATIVE TO T1/2: 

ALTERNATIVE TO T1/2 The following parameters were calculated: the time to the maximum of the basic renogram ( Tmax ); the normalized residual activity (NORA) and Renal output efficiency (ROE),Pelvic excretion efficiency(PEE) a late image was acquired Post Micturition (PM) and after changing the position of the patient. The quality of drainage obtained during the F+20 and F0 procedures can easily be compared using both ROE and NORA. A very similar quality of drainage was reached for both procedures when considering only the PM image. This PM view remains mandatory irrespective of the timing of the furosemide injection and despite the use of tracers with a high extraction rate. Eur J Nucl Med Mol Imaging DOI 10.1007/s00259-011-1811-3

SRn: 

SRn the normalized slope ratio (SRn). This ratio is calculated from the division of the maximum renal clearance slope by the maximum renal up take slope, both normalized to peak renal activity. J NucI Med 1993; 34:762-768 In routine diuretic renogram of children The main causes of interpretative errors are collecting system dilatation and impaired renal function.-false positive The SAn takes into account the renal uptake curve, whose slope is dependent on glomerular function, and thus may correct for Renal dysfunction.It also differentiates obstructed from patent kidneys even in cases with significant collecting system dilatation.

PowerPoint Presentation: 

BJU Int. 2002 Jul;90(1):72-5. Does delaying pyeloplasty affect renal function in children with a prenatal diagnosis of pelvi-ureteric junction obstruction? In patients with an antenatal diagnosis of PUJ obstruction, expectant management is recommended and spares the children unnecessary surgery. Even if renal function deteriorates, delayed pyeloplasty recovers the initial functional level.

PowerPoint Presentation: 

Does early detection of ureteropelvic junction obstruction improve surgical outcome in terms of renal function? whether the antenatally detected hydronephrotic child should undergo surgery or not.?

Antenatal detection of pelviureteric junction stenosis: main controversies. Semin Nucl Med. 2011 Jan;41(1):11-9 : 

Antenatal detection of pelviureteric junction stenosis: main controversies. Semin Nucl Med. 2011 Jan;41(1):11-9 It is generally admitted that the first renogram in children with antenatally detected hydronephrosis should be performed at approximately 1 month of age. However, there is a tendency to start earlier, and even in the first days of life, in case of huge hydronephrosis. The renogram should be repeated in case of significant hydronephrosis, significant increase of dilation, poor response to furosemide, or low initial differential function. Moderate dilation associated with normal differential function can probably be monitored by ultrasound alone.

LT KIDNEY: 

LT KIDNEY

The main controversy is related to the definition of obstruction and the indication for surgery: 

The main controversy is related to the definition of obstruction and the indication for surgery Neither the degree of hydronephrosis nor the impairment of differential function and/or the quality of the response to furosemide can define which kidney is in danger of further deterioration. Alternatively, these parameters are unable to predict for which kidneys an improvement of differential function can be expected because of a pyeloplasty. It has not been excluded, according to recent published work, that cortical transit could be a better predictive factor of the risk of a conservative attitude or the benefits of a surgical procedure, but this procedure has still to be confirmed.

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J Urol. 1999 Sep;162(3 Pt 2):1041-4. Renal function before and after pyeloplasty: does it improve? Renal function did not improve after pyeloplasty regardless of the initial level of relative function. Renal scan revealed that differential function decreased after pyeloplasty in some patients in whom hydronephrosis was detected prenatally and who were initially followed with observation. In our opinion waiting for renal function to decrease before considering pyeloplasty is not warranted, since function does not improve even when obstruction is corrected and drainage time improves.

OVER ESTIMATION OF DRF: 

OVER ESTIMATION OF DRF 9 month girl RT hydroneohrosis 6month FW J Nucl Med June 1, 2011 vol. 52 no. 6 905-925

O’Reilly: 

O’Reilly

IMPORTANCE OF GFR: 

IMPORTANCE OF GFR To make diuretic study definitive, renal function must be at least partially preserved. The glomerular filtration rate (GFR) must be greater than 15 mL/min for an obstructive time-activity curve to be judged accurate. In patients where the GFR is less than 15 mL/min, no response to the administration of furosemide is observed. No washout of activity occurs regardless of the presence or absence of obstruction. Thus, the study is deemed indeterminate and further workup or intervention is required to make the diagnosis.

BILATERAL HYDRONEPHROSIS: 

BILATERAL HYDRONEPHROSIS

2011 DJ STENT 2012: 

2011 DJ STENT 2012

POST PYELOPLASTY: 

POST PYELOPLASTY Is routine renography required after pyeloplasty? function less than 45% may exhibit functional changes greater than 5% that can be determined by postoperative renal scan. J Urol. 2010 Sep;184(3):1128-33. Epub 2010 Jul 21 Follow-up after pyeloplasty: How long? to determine which patients with poorly functioning kidneys after pyeloplasty are at risk of developing hypertension, infection, proteinuria or pregnancy-related problems. recurrence of the obstruction was unlikely and did not justify a long-term follow-up. But

Prediction of function: 

Prediction of function Ann Nucl Med. 2003 Dec;17(8):663-8. Differential renal function in the prediction of recovery in adult obstructed kidneys after pyeloplasty. Renal function improves after pyeloplasty with regard to the initial level of split renal function in adult obstructed kidneys. Improvement may not be observed especially in patients with DRF less than 30%.

Follow up post pyeloplasty: 

Follow up post pyeloplasty

V-U REFLUX RNC : 

V-U REFLUX RNC . The international classification of reflux by vesicoureterogram includes 5 grades (I–V) of severity . RNC grade 1 refers to reflux within the distal ureter only and not reaching the renal pelvis (equivalent to vesicoureterogram grade I). Typically, 0.2 mL of reflux that projects at least 2 cm away from the projected border of the bladder can be detected. RNC grade 2 refers to reflux that reaches the renal pelvis, without pelvic dilatation and without a dilated or redundant ureter (equivalent to vesicoureterogram grades II and III). RNC grade 3, the most severe, shows reflux into the renal pelvis with significant dilatation of the pelvis or tortuosity of the ureter (equivalent to vesicoureterogram grades IV and V) . Reflux can be detected during one or all phases: early, mid, or late filling; voiding; and after voiding

DMSA SCAN: 

DMSA SCAN

RENAL SCAN USAGE IN UTI: 

RENAL SCAN USAGE IN UTI

DMSA RENAL SCAN controversy: 

DMSA RENAL SCAN controversy Controversy exists regarding the type and/or sequence of imaging studies needed during the first febrile urinary tract infection (UTI) in young children. Several investigators have claimed that because acute-phase Tc-99m dimercaptosuccinic acid (DMSA) renal-scan results are abnormal in the presence of dilating vesicoureteral reflux, a normal DMSA-scan result makes voiding cystourethrography (VCUG) unnecessary in the primary examination of infants with UTI. Review Article Acute Tc-99m DMSA Scan for Identifying Dilating Vesicoureteral Reflux in Children: A Meta-analysis 2011 by the American Academy of PediatricsAcute-phase DMSA renal scanning cannot be recommended as replacement for VCUG in the evaluation of young children with a first febrile UTI. DMSA renal scans in adults with acute pyelonephritis- the DMSA scan may prove to be the most useful renal imaging procedure.

RNC: 

RNC

ADVANTAGES OF RNC: 

ADVANTAGES OF RNC

TX DONE 5YRS Back creatinine=3 : 

TX DONE 5YRS Back creatinine =3

HIV+: 

HIV+ TX DONE 1 YR BACK CREATININE=1.8

TX FOLLOWUP: 

TX FOLLOWUP

SUMMARY: 

SUMMARY The advatanges of radionuclide studies in the management of patients with urinary system obstruction involve the estimation of obstruction degree and parenchymal function to predict potential recovery as well as the evaluation of the recovery after treatment applied. Safe ,simple and reproducible. Radionuclide studies provide semiquantitative or quantitative informations on renal perfusion, parenchymal function and urine flow