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Society of Nuclear Medicine Procedure Guideline for

Diuretic Renography in Children
version 2.0, approved February 7, 1999

Authors: Gerald A. Mandell, MD (DuPont Hospital for Children, Wilmington, DE); Jeffrey A. Cooper, MD (Albany Med-
ical Center, Albany, NY); Joe C. Leonard, MD (Oklahoma Children’s Memorial Hospital, Oklahoma City, OK); Massoud
Majd, MD (Children’s National Medical Center, Washington, DC); John H. Miller, MD (Children’s Hospital Los Angeles,
Los Angeles, CA); Marguerite T. Parisi, MD (Children’s Hospital Los Angeles, Los Angeles, CA); and George N.
Sfakianakis, MD, PhD (University of Miami School of Medicine, Miami, FL).

I. Purpose spontaneously and is related to physiologic change
during early development. The diagnosis of ob-
The purpose of this guideline is to assist nuclear
struction often requires sequential scintigraphic ex-
medicine practitioners in recommending, perform-
aminations.
ing, interpreting, and reporting the results of di-
uretic renography in children.
III. Common Indications
II. Background Information and Definitions A. Ureteropelvic or ureterovesical obstruction
Hydronephrosis (distension of the pelvicalyceal sys- B. Prenatal ultrasound diagnosis of hydronephrosis
tem) is one of the most common indications for ra- C. Post-surgical evaluation of a previously ob-
dionuclide evaluation of the kidneys in pediatric pa- structed system
tients. The etiology of the hydronephrosis can be an D. Distension of pelvicalyceal system as an etiology
obstructed renal pelvis, an obstructed ureter, vesi- of back pain
coureteral reflux, the bladder itself or the bladder
outlet, infection or congenital in nature.
IV. Procedure
Contrast intravenous urography, ultrasonogra-
phy and conventional radionuclide renography A. Patient Preparation
cannot reliably differentiate obstructive from nonob- 1. Preparation prior to arrival in department
structive causes of hydronephrosis and hydroure- Preparation is usually not necessary. If the pa-
teronephrosis (distension of the pelvicalyceal sys- tient is not going to receive intravenous flu-
tem and ureter). ids, oral hydration is encouraged prior to ar-
The pressure perfusion study (Whitaker test), which rival and while in the department.
measures collecting system pressure under conditions 2. Preparation prior to injection of the radio-
of increased pelvic infusion, is relatively invasive. pharmaceutical
The evaluation of function in the presence of ob- a. The procedure is explained to parents and
struction does not give reliable indication of poten- all children old enough to understand.
tial for recovery following surgical correction. High b. Continual communication and reassurance
pressure in the collecting system results in reduction with explanation of each step is essential
of renal blood flow and function. for cooperation and successful intravenous
The most common cause of unilateral obstruction injection of the radiopharmaceutical and
is the presence of a ureteropelvic obstruction. Ob- catheterization of the bladder.
structions can also occur more distally at the c. Oral hydration may be sufficient in certain
ureterovesical junction. Bilateral hydronephrosis can situations. Intravenous hydration is more
be produced by posterior urethral valves, bilateral reliable in the diagnosis of questionable
ureteropelvic obstructions or even a full bladder. cases of urinary obstruction. An in-
The purpose of diuretic renography is to differen- dwelling venous catheter may be inserted
tiate a true obstruction from a dilated nonobstructed to maintain sufficient hydration for a good
system (stasis) by serial imaging after intravenous diuretic effect and obviate the necessity for
administration of furosemide (Lasix). repeated traumas from multiple percuta-
Hydronephrosis detected in utero may resolve neous injections.
160 • PEDIATRIC DIURETIC RENOGRAPHY

d. Bladder catheterization is not always nec- 4. An allergy to sulfa drugs may prevent usage
essary, but is suggested. In some cases, of furosemide (cross reactivity between sulfa
the diagnosis of obstruction may be more and furosemide) in a small percentage of pa-
reliable with bladder catheterization. tients. Urethral anesthesia with xylocaine
Older children, who are not catheterized, should not be used in patients with an allergic
are requested to void completely prior to history to lidocaine or its derivatives.
the study. C. Precautions
i. Sterile urethral catheterization should 1. The examination table is covered with plastic-
be performed with the largest size Fo- lined absorbent paper to contain spilled tracer
ley or feeding catheter that will com- and reduce contamination of the table during
fortably pass the meatus (a 2.6 mm di- drainage and catheterization.
ameter catheter [French #8] for most 2. Gentle catheterization by a qualified individ-
patients and 1.8 mm diameter [French ual can prevent an overly traumatic and
#6] for infants). A #8 French feeding painful experience and results in better coop-
catheter may also be used for continual eration during follow-up examinations.
bladder drainage. 3. Slow, deep breathing and a gentle forward
ii. Continual drainage by catheterization motion of the catheter should be used to relax
of bladder is required in patients with the spastic external sphincter.
hydroureter, vesicoureteral reflux, 4. An application of urethral anesthesia (3 to 5
neurogenic bladder, a small capacity ml of lidocaine jelly) in the male urethra 2 to 5
bladder, dysfunctional bladder, or pos- min before catheterization helps decrease the
terior urethral valves. patient’s discomfort.
iii. The diuretic effect can be assessed by 5. A Foley balloon is only inflated after catheter
comparing the volume of urine ex- and its balloon are confirmed to be in the
creted during the dynamic phase and bladder. Urine return can be appreciated with
the volume of urine excreted during balloon still positioned in the posterior ure-
the diuretic phase. thra. The balloon must be deflated prior to re-
e. The patient is usually hydrated intra- moval from the patient’s bladder. When a
venously (10–15 ml/kg of D5 0.22% NS for feeding tube is used for bladder drainage,
under 1 yr of age and D5 0.45% NS for over premeasurement of catheter length may pre-
1 yr of age) for thirty min prior to adminis- vent excessive instillation.
tering the diuretic. The slow administra- 6. Caution should be observed with postural
tion of fluid is continued during the re- changes because of possible diuresis-induced
mainder of the study. hypotension.
f. If the rate of urine flow is low during hy- 7. Sudden abdominal or flank pain can arise
dration, a larger amount of fluid (up to 40 during acute distension of the pelvicalyceal
ml/kg) can be administered. system in some patients.
g. Some laboratories do not use intravenous 8. There is a small risk of catheter-induced
hydration or catheter bladder drainage for trauma and infection.
the initial evaluation (particularly in older D. Radiopharmaceuticals
children) so that kidneys can be evaluated 1. Technetium-99m diethylene triamine pen-
without intervention. taacetic acid (Tc-99m DTPA) is a glomerular
B. Information Pertinent to Performing the agent. The biological half life is under 2.5 hr.
Procedure 95% of the administered dose is cleared by
1. A prenatal history of urinary tract obstruction, 24 hr.
history of prior surgery to the urinary tract 2. Tc-99m mercaptoacetyltriglycine (Tc-99m
and congenital urinary abnormalities (duplex MAG3) is cleared by tubular secretion. After
systems, renal fusion, etc.) are important for about three hr, 90% of the injected dose can be
accurate interpretation of the study. recovered in the urine.
2. The review of available past radiographic, ul- 3. Tc-99m MAG3 has a high initial renal uptake,
trasound and radionuclide studies adds to the providing high kidney/background ratios
accuracy of interpretation of the current study. with good temporal resolution. It is recom-
3. Nonlatex materials should be used in patients mended for neonatal renography and for vi-
prone to latex allergy (e.g. congenital spinal sualization of kidneys in patients with com-
defects and chronic urethral catheterization). promised renal function.
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL JUNE 2002 • 161

4. Iodine-131 orthoiodohippurate (OIH) (Hip- jected at 20 min or later after the radio-
puran) is cleared by tubular excretion (80%) pharmaceutical (F + 20 or later) when the
and glomerular filtration (20%) with ninety renal pelvis and ureter become maximally
percent clearance in the first pass through the distended in hydronephrosis and hy-
kidney. The patient must be premedicated droureter respectively. Maximal disten-
with several drops of potassium iodide oral sion is usually determined by visual in-
solution (SSKI). spection of the images.
5. The minimal administered activity for Tc-99m b. In the method developed in Europe, the di-
DTPA is about 20 MBq (0.5 mCi). The maxi- uretic is injected 15 min prior to the injec-
mum administered activity for Tc-99m DTPA tion of the radiopharmaceutical (F–15) and
is about 375–750 MBq (10–20 mCi) in imaging is continued for thirty min after
teenagers who weigh over 70 kg. the injection of the radiopharmaceutical.
6. The minimal administered activity for Tc-99m F. Image Acquisition
MAG3 is about 20 MBq (0.5 mCi). The maxi-
1. The preliminary study is a dynamic renal scan
mum administered activity for Tc-99m MAG3
with the patient supine with his/her back to
is about 375–750 MBq (10–20 mCi) in
the camera and acquisition for 20 to 30 min as
teenagers who weigh over 70 kg.
serial 15 to 30 sec images (64 x 64 or 128 x 128
7. The minimal administered activity for I-131-
matrix format). After the first few min, 30 to 60
OIH is about 1.0 MBq (0.025 mCi). The maxi-
mum administered activity for I-131-OIH is sec images may be acquired. This format can be
about 7 MBq (0.2 mCi). used for the pre-diuretic phase of F + 20 or
E. Interventions later, or F–15 acquisition.
1. The dose of furosemide (Lasix) is 1.0 mg/kg 2. For the diuretic phase, the supine position
with a usual maximum dose of 40 mg. A permits the least motion and is recommended
higher diuretic dose may be necessary in cases for infants and most children. The sitting po-
of severe renal failure. sition is occasionally necessary but can result
2. There are two validated, but different ap- in motion, even in the most cooperative child.
proaches for the time of injection of the di- 3. The diuretic effect usually begins within 1 to 2
uretic furosemide (F). min after the administration of the diuretic.
a. In the method endorsed by the American 4. For the diuretic phase of F + 20 or later, con-
Society of Fetal Urology, the diuretic is in- tinuous computer and analog acquisitions are
begun one to two min prior to the administra-

Radiation Dosimetry in Children*
(5 year old)

Radiopharmaceutical Administered Activity Organ Receiving the Effective Dose+
Largest Radiation Dose+
MBq/kg mGy mSv
(mCi/kg) (rad) (rem)
Tc-99m DTPA 3.2 – 4.2 0.086 0.012
bladder wall
(0.08 – 0.12) (0.32) (0.044)
Tc-99m MAG3 3.2 – 4.2 0.17 0.015
bladder wall
(0.08 – 0.12) (0.63) (0.056)
I-131 OIH 0.08 – 0.12 1.7 0.12
bladder wall
(0.002 – 0.004) (6.3) (0.44)
*Treves ST. Pediatric Nuclear Medicine. 2nd Edition. Springer-Verlay, 1995, pp. 567-569.
+
Per MBq (per mCi)
162 • PEDIATRIC DIURETIC RENOGRAPHY

tion of the diuretic (the baseline phase) and of the washout study has been used for differ-
for the rest of the study. entiation of stasis from obstruction.
5. The computer is set to record 15 to 60 sec I. Reporting
frames for the baseline phase and for the ad- 1. The procedure, date of the study, amount and
ditional 30 min with a 64 x 64 or 128 x 128 ma- route of administration of the radiopharma-
trix format. ceutical, and previous study for comparison
G. Processing are included.
1. From the dynamic renal study, careful evalu- 2. The history includes symptoms and/or di-
ation of the parenchymal phase reveals renal agnosis.
function, size and position. Cortical transit 3. The technique includes catheter size and type
time and dilatation of the collecting system if implemented, amount and kind of i.v. fluid
are examined on the excretory phase. if administered, the imaging sequence, the
2. Baseline images of the diuretic phase are used amount and time of diuretic administration,
for the assessment of the diuretic effect. and the urine volumes pre- and post-diuretic
3. Cinematic viewing of the diuretic phase as- if measured.
sesses patient movement. If there is consider- 4. The findings may include renal perfusion,
split renal function, progression of activity,
able patient motion, regions of interest
and the T 1/2 of collecting system emptying
around the collecting systems of individual
post-diuretic.
frames will have to be compared at various
J. Quality Control
time intervals of the study to assess drainage.
There are no issues of quality control.
4. Regions of interest are drawn around the di-
K. Sources of Error
lated pelvicalyceal system for curve analysis
1. Infiltration of the radiopharmaceutical or di-
and calculation of the T 1/2. One to two back-
uretic may invalidate the results.
ground regions can also be drawn. The reader
2. Insufficient hydration can result in delayed
is referred to a standardized technique of the
uptake and excretion, simulating poor func-
“well-tempered” diuretic renogram. tion, or demonstrate a normal response in the
5. The diuretic half-time is the time at which the presence of significant obstruction.
time-activity curve decreases to half of its 3. If the diuretic is administered prior to the
maximal activity. maximum distension of the collecting system,
6. Residual activity can be reported by estimat- the response may not reflect the true physio-
ing the percentage of the initial tracer activity logic state.
that remains at 30 min after the injection of the 4. Poor renal function from prolonged severe ob-
radiopharmaceutical. struction can result in slow tracer accumula-
H. Interpretation Criteria tion in the dilated collecting system and result
1. The diuretic effect usually begins within 1 to 2 in difficult interpretation of the diuretic phase.
min after the administration of the diuretic. 5. With severe compromise of function (less
2. In absence of obstruction, there is rapid and than 20%), the diuretic response to
almost complete washout of the radiotracer. furosemide (a tubular effect) may be difficult
3. Obstructed systems can result in delayed to evaluate when using Tc-99m DTPA, a
drainage from the collecting system. The glomerular agent.
amount of activity proximal to the obstruction 6. A large, unobstructed collecting system with
can also increase in time. relatively good renal function can exhibit slow
4. With the injection of the diuretic after the ra- drainage of the radiotracer (prolonged T 1/2).
diopharmaceutical (F + 20 or later), a T 1/2 less 7. When the obstruction is at both pelvicalyceal
than 10 min usually means the absence of ob- and ureterovesical junctions, it may be diffi-
struction, where a T 1/2 greater than 20 min cult to detect the ureterovesical junction ob-
identifies obstruction. The T 1/2 with a value struction. A repeat evaluation may need to be
between 10 and 20 min is an equivocal result. performed following the surgical correction
However, some observers consider T 1/2 of 10 of the ureteropelvic junction obstruction.
to 15 min as probably normal. 8. Patient movement may invalidate curve
5. With the injection of the diuretic prior to the analysis.
radiopharmaceutical (F–15), the T 1/2 greater 9. Urinary systems considered normal on the
than 20 min is compatible with obstruction. dynamic study should not be evaluated for
6. The shape of the resulting time activity curves drainage. A prolonged T 1/2 can be obtained
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL JUNE 2002 • 163

because of the relatively small amount of Meller ST, Eckstein HB. Renal scintigraphy: quantitative
residual activity in the collecting system to re- assessment of upper urinary tract dilatation in chil-
spond to the diuretic challenge. dren. J Pediatr Surg 1981;16:123–126.
Senac MO, Miller JH, Stanley P. Evaluation of obstruc-
tive uropathy in children: radionuclide renography
V. Issues Requiring Further Clarification
versus the Whitaker test. AJR 1984;143:11–15.
A. The calculation method of the diuretic half-time Wackman J, Brewer E, Gelfand MJ, et al. Low grade
is variable, but a standardized technique is avail- pelviureteric obstruction with normal diuretic
able in the literature. renography. Br J Urol 1986;58:364–367.
B. The curve analysis has been questioned because Whitaker RH, Buxton TMS. A comparison of pressure
of poor correlation with pressure perfusion stud- flow studies and renography in equivocal upper
ies in children. tract obstruction. J Urol 1986;131:446–449.
C. The results of alternative method of simultane-
ous injection of the radiopharmaceutical and di-
uretic remain to be validated. VIII. Disclaimer
D. Guidelines for doses of Lasix above usual maxi- The Society of Nuclear Medicine has written and
mums. approved guidelines to promote the cost-effective
use of high quality nuclear medicine procedures.
VI. Concise Bibliography These generic recommendations cannot be applied
to all patients in all practice settings. The guidelines
Conway JJ. Radionuclide cystography. In: Tauxe WN,
Dubovsky EV, eds. Nuclear Medicine in Clinical should not be deemed inclusive of all proper proce-
Urology and Nephrology. East Norwalk, CT: Apple- dures or exclusive of other procedures reasonably
ton, Century & Crofts; 1985:305–320. directed to obtaining the same results. The spec-
Conway JJ. “Well-tempered” diuresis renography: its trum of patients seen in a specialized practice set-
historical development, physiological and technical ting may be quite different than the spectrum of pa-
pitfalls, and standardized technique protocol. Sem tients seen in a more general practice setting. The
Nucl Med 1992;22:74–84. appropriateness of a procedure will depend in part
Foda MM, Garfield CT, Matzinger M, et al. A prospec- on the prevalence of disease in the patient popula-
tive randomized trial comparing 2 diuresis renog- tion. In addition, the resources available to care for
raphy techniques for evaluation of suspected upper patients may vary greatly from one medical facility
urinary tract obstruction in children. J Urol to another. For these reasons, guidelines cannot be
1998;159:1691–1693. rigidly applied.
Kass EJ, Majd M. Evaluation and management of the Advances in medicine occur at a rapid rate. The
upper urinary tract obstruction in infancy and date of a guideline should always be considered in
childhood. Urol Clin NA 1985;12:122–141. determining its current applicability.