Imaging in Nephrology

Dr Arshalooz J Rahman
 OBJECTIVES
Role plain x-ray
IVP
ULTRASOUND KUB
MCUG
NUCLEAR IMAGING
 Plain film KUB
Full length abdominal film
Upper abdomen cross kidney
Supine
Low voltage 60 – 65kv to enhance soft tissue
contrast
Unreliable diagnostic tool
50% accuracy for ureteric calculi
 Calcification on KUB
Renal: Calculi, carcinoma, T.B, atheroma, aneurysm.
Ureter: calculi, T.B, Schistosomisis
• Extra renal:
Musculoskeletal: costal cartilage
Hepatobiliary: gall stone, granuloma
Pancreas:chronic pancreatitis
Adrenal: T.B
Aorta : atheroma
Venous : phlebolith
Uterine fibroid
Lymphatic: calcified node
 Intravenous pyelography
Water soluble iodine containing contrast
injected
4 hrs NPO AND FLUID DEPRIVATION
Bowel prep
0 , 5 , 15 min, full length release, post void
Films, abdominal compression is given after 5
min film to inhibit ureteric drainage,to
promote pelvicalyceal system
High Risk of contrast nephropathy
 Ultrasound KUB
Indication;
UTI
Hematuria,
obstruction, calculi,congenital anomalies
masses
renal failure
MEDULARY NEPHROCALCINOSIS
OBSTRUCTION OF URINARY
TRACT

Is it unilateral or bilateral ?
Are the ureters involved ?
What is the state of the bladder ?
DILATED URETER
VUR: distal ureter
PUV:distal ureter
PUJO: proximal ureter
 CYSTIC LESIONS
MCDK : large non functioning kidney
numerous cysts, atresia of the ureter.
Dysplastic : small and bright
Note; atretic ureter is prerequisite to label
MCDK.
Large hydronephrotic DUE TO PUJ
OBSTRUCTION lesions also appear like
MCDK
U/S KUB
MCDK multicystic
dyplastic kidney
U/S KUB
PUJ:
MCDK HYDRONEPHROTIC
 MCUG
CONTRAST 20% Iodine
6 to 8 fr catheter
INDICATIONS: Bladder anatomy,
urethra in male,vesicoureteric junction
visualization.
CONTRAINDICATION:
F/U VUR
Bladder function
Used to identify and grade reflux

Also evaluates the urethra and bladder

for abnormalities – important for boys
who may have posterior urethral valves
and girls with voiding dysfunction
MCUG
PUV
WHAT DOES THIS IMAGE SHOW ?
ISOTOPE SCAN
DMSA, DTPA, MAG 3
 Tc- DTPA :(tecnecium-99m
diethyienetriamine pentaacetate)
Small molecule
Not protein bound
Diffuses freely across capillary bed
Tc MAG 3 : ( mercaptoacetyltriglycine)90%
protein bound
More tracer is presented to the kidney at a
given time there for better definition of
images
 PHYSIOLOGY OF RENAL ISOTOPES

DTPA MAG 3 DMSA

% prot binding 1 90 70
in blood
Renal 20 40 6 -- 8
%extraction
fraction
GFR % 100 1 80
Proximal Tubular
Function 0 99 0
Excretion %
Absorption%
0 0 90
Distal tubular % 0 0 0
% in urine 100 100 10
 Radioisotope scan
DYNAMIC SCAN
PHYSIOLOGY:
BLOOD FLOW PHASE: Rate of arrival of
tracer to kidney 10 –20 sec reflects
renal blood flow
CLEARANCE PHASE
Removal of tracer from blood as it passes
through kidney
 IMPORTANCE OF CLEARANCE PHASE
Tc 99 DTPA SCAN:
Reflects GFR
Tc 99 MAG 3 SCAN:
PCT excretory function
differential GFR rate-- DTPA
differential PCT excretion rate– MAG 3
Time : 80 – 150 seconds
 EXCRETORY PHASE
3-5 Min after inj. Tracer is seen in pelvis
GOOD DRAINAGE: 75% FALL IN CURVE
With in 3 to 5 min
Poor response
-gross dilatation of renal system
-poor renal function
-full bladder
 Renal Cortical Scintigraphy
(DMSA)
Very sensitive for evaluating acute
inflammation from pyelonephritis as
well as renal scarring
Role in clinical management is still
unclear
DMSA
DMSA
DMSA
 Differential renal function
Intact Nephron hypothesis: either glomerulus
and tubule of an individual nephrone function
in harmony

Tc DTPA Scan : differential GFR

Tc MAG 3 Scan: differential proximal tubular
function.( excretion)
Tc DMSA Scan: proximal tubular and loop of
henle function(uptake)
 Special circumstances
Tc DMSA- tubular immaturity in neonate
poor visualization– 3 months
Tc DTPA SCAN more back ground
activity less renal visualization- 3
months
Tc MAG 3 better excretion of isotope
better visualization – 3-4 wks
 CT/MRI
WILMS TUMOR
NEUROBLASTOMA
MASS / BLEED
CASE DISCUSSION
 CASE #1
A mother has an antenatal scan showing
moderate hydronephrosis at 34 weeks , she
is at term now and wants to have an opinion
how will you follow her baby;
Report of the u/s is as follows:
Right sided hydronephrosis pelvis 10 mm
with dilated Rt proximal ureter .
repeat ultrasound in first week to
confirm diagnosis
If findings persist then MCUG Will
be done.
Follow-up ultrasound of baby 10th
day of life#1
Rt Sided Hydronephrosis with pelvis size
15 mm good cortico medullary
differentiation on both sides dilated
right ureter.
What will be your approach?
MCUG
 What is your diagnosis and how
will you manage?
Grade 4 VUR
Start prophylactic antibiotic
Explain risk of break through infection.
Antibiotic choice
6 WEEKS OF AGE
And after 6 weeks
 Case #2
A baby Boy has been referred by the
neonatal team for not being able to
pass urine at 48 hours of life, mother
has bad antenatal history with no
previous antenatal ultrasound.
What points in history and examination
you will ask?
• Was the baby fed adequately?
• Palpate bladder,
• Examine spine
• Bladder is palpable.
• What you will do now?
• Catheterize decompress and send
sample for Urine d/r and c/s
• Order urgent ultrasound
Ultrasound shows normal kidneys with
thick wall bladder.
What will be the next step?
Urine Dr is negative for infection and
c/s is pending
Start prophylactic abx : 3 day plan if no
infection
order MCUG
MCUG CASE#2

Post urethra

urethral valve
 MANAGEMENT CASE #2
Refer to pediatric surgeon
1. vesicostomy
2. valve ablation
 Case #3
A 3 month old baby has been admitted
with sepsis blood culture grew Ecoli and
he is on appropriate antibiotic .Mother
states that he was admitted to nicu
soon after birth for infection and
prolonged jaundice.At that time he had
an ultrasound which showed Left Sided
Hydronephrosis With Dilated Proximal
Ureter .On discharge she was asked for
follow up after 2 weeks which she did
not.
What is your thoughts on this
case?
Repeat ultrasound shows right sided
pyonephrosis.
Treat infection/ percutaneous drainage.
Order MAG 3 scan
 R

R
L
 Case #4
A 5 year old girl has been coming for
recurrent UTI culture proven 3 episodes
over the past 6months.
Ultra sound kub shows a dilated ureter
on Left side and hydronephrosis right
side.
What will be your next step
Urine culture
If negative then prophylax
MCUG
After 6 weeks months DMSA
MCUG
 DMSA

RT= 70%
LT= 30%

Anterior
After deflux surgery B
Thank you