RENAL ISOTOPE SCAN

MD FAIZUL HAQUE
NUCLEAR MEDICINE IS FUNCTIONAL IMAGING

• To visualise an organ needs a contrast with the

surrounding tissue.
• Radiography/CT needs difference in density.
• MRI needs difference in protons.
• Ultrasound needs difference in reflectivity.
• Nuclear Medicine needs difference in function.
 ISOTOPES
 Any given element may have many isotopes
 All isotopes of a given element have the same no
of protons and differ only in the no of neutrons
 Some of these isotopes have unstable nuclear
configuration and seek greater stability by
decay/disintegration to a more stable form
 Isotopes attempting to reach stability by emitting
radiation are called radionuclides/radioisotopes
 TECHNETIUM99M
 Fulfills many criteria of ideal radionuclide
 No particulate emission
 6 hour half life
 A predominant (98%) 148KeV photon
conversion
 Used in > 70% of nuclear imaging procedures
in United States
 RENAL SCINTIGRAPHY
INDICATIONS
 Renal perfusion and function
 Urinary Tract Obstruction (Furosemide renal scan)
 Reno-vascular HTN (Captopril renal scan)
 Infection (renal morphology scan)
 Pre-surgical quantitation (nephrectomy)
 Renal transplantation
 Congenital anomalies/masses(renal morphology
scan)
RADIOPHARMACEUTICAL AGENTS
Grouped into three categories:
Those excreted by glomerular filtration,

 Those excreted by tubular secretion, and

 Those retained in the renal tubules for

long periods
RADIOPHARMACEUTICAL AGENTS
Glomerular Agents

Tc 99m DTPA

Cr-EDTA
51

I 125 Iothalamate
 GLOMERULAR FILTRATING AGENTS
TC-99M DTPA
(DIETHYLENETRIAMINE PENTAACETIC ACID)
COOH

COOH
N

HOOC
N

COOH

COOH
 TC 99M DTPA
• Inulin clearance remains the gold standard to
measure GFR, but it is expensive, time
consuming, and requires a steady-state plasma
concentration and accurate and timed urine
collection
• 99mTc-DTPA is recommended agent is for GFR

measurement.
• 5- 10% plasma protein binding, so it tends to
underestimate the GFR(insignificant)
PEAK RENAL ACTIVITY AFTER 3 – 4 MIN. 90 %
FILTERED WITHIN 4 HOURS.
The extraction fraction of 99mTc-DTPA is
approximately 20 per cent; for this reason,
not useful for imaging , in patients with
impaired renal function.
In such cases, agents with higher extraction
efficiencies such as 99mTc-MAG3 more
appropriate.
 CR-EDTA, WHICH MAY PROVIDE MORE ACCURATE
51

values for GFR, but cannot be used for

imaging.
TUBULAR SECRETING AGENTS:

 I131/I123 OIH
 Tc99m MAG3
 Tc99m EC
 I-131/I-123
ORTHOIODOHIPPURATE

-C- NH- CH2- COOH

Chemical structure similar to the Paraaminohippuric acid

 I-131 OIH

Secreted by tubules – 80% & glomerular

filtration - 20%
Chemically & pharmacokinetically similar
to PAH
Plasma protein binding – 70%
Cortical peak time = 3-5 min
Radiation absorbed dose to bladder= 0.74
rad/mCi
THE MAIN DISADVANTAGES OF 131I-OIH ARE THE SUBOPTIMAL
IMAGING CHARACTERISTICS OF 131I.

I-OIH has better imaging qualities, but 123I is

123

more expensive and less available.

 TC99M MAG3
(MERCAPTOACETYL TRIGLYCINE)

CH2- COO

S O N

Tc

O
N N
O
 TC99M MAG3

 70 – 90 % PROTEIN BINDING
 89% TUBULAR SECRETION
 11% GLOMERULAR FILTRATION
 Extraction fraction of 40-50%.
 Provides a high target-to-background ratio, good
image quality, and more accurate numerical
values, particularly when the kidney function is
low or immature
 5 TO 10 mCi i.v. ( ADULTS)
 TC99M L,L-EC
(ETHYLENE DICYSTEINE)

N N
-ooc coo-
Tc
S S

Exists in 4 different forms D,D- EC; L,L- EC; D,L- EC & L,D- EC
 EC:

 Metabolite of the L,L-ECD(ethylene

cystine dimer) with cortical uptake
 Secretion in proximal convoluted tubules
 Plasma protein binding is 50%
 Exact excretion mechanism is not known
 Clearance is 69-85% .
CORTICAL BINDING AGENTS:
 Tc99m DMSA

 Tc99m GHA
 TC-99M DMSA
(DIMERCAPTOSUCCINIC ACID)

HS COOH

HS COOH

H
 CORTICAL AGENTS
 Tc99mDMSA-
PYELONEPHRITIS, INFARCTS, SCARS, ANOMALIES
 75% protien binding in 6 hrs
 5- 20 % excretion 2 hrs
 37% excretion in 24 hrs
 40-50% cortical localisation
 Maximum activity at 3-6 hrs
 2 TO 5 mCi i.v.
 Images at 2 – 4 hrs
 IMPORTANTLY, ACUTE INFECTION
CAN PRODUCE ABNORMALITIES IN
THE SCAN; AND IF THE TEST IS BEING
PERFORMED TO EVALUATE FOR
CORTICAL SCARRING, IT
SHOULD BE DONE AT LEAST 3
MONTHS AFTER AN ACUTE
INFECTION .
 TC 99M GHA
(GLUCOHEPTONATE)

O
O O O
O
C Tc C

CH CH
O O
(CHOH) 4 (CHOH) 4

CH2OH CH2OH
 Tc 99m GH
 It is both filtered by the glomerulus and bound by
the tubules.
 Glomerular filtration 80-90%
 Tubular secretion 10-20%
 25-40% in 1 hr & 70% in 24 hrs in urine
 15% bound to PCT
 EARLY DYNAMIC FUNCTIONAL imaging
DELAYED CORTICAL imaging
 10-15 mCi
CHOOSING RENAL RADIOTRACERS

Clin. Question Agent

Perfusion MAG3, DTPA, GHA
Morphology DMSA, GHA
Obstruction MAG3, DTPA, OIH
GFR quantitation I-125 iothalamate,
Cr-51 EDTA, DTPA
ERPF quantitation MAG3, OIH
DIURETI C (LASIX) R E N A L
SCAN
 PATIENT PREPARATION

 Patient must be well hydrated

 Give 5-10 ml/kg water (2-4 cups)
30-60 min. pre-injection
 Can measure U - specific gravity (<1.015)
 Void before injection
 Void @ end of study
• H y d r o n e p h r o s i s – tracer p o o l i n g I n
dilated r e n a l p e l v i s
• Lasix induces I ncreased u r i n e f low
• I f obstructed >>>will not wash out
• I f d i l a t e d, non- ob st ru ct ed >>> will wash
out
• C a n quantitate rate of washout(T1/2)
• T r acer s : TC-99M MAG3 5-10 MCI

• Acquisition: s u p i n e until p e l v i s f u l l
(c a n switch to sitting post-Lasix)
• Flow (a n g i o g r a m) : 2-3 sec / f rame x 2 min then 1 sec f o r 1
m in
The flow phase shows renal uptake, background clearance,
and abnormal vascular lesions, which may indicate arteriovenous
malformations, tumors, or active bleeding
• Renal phase: 60 sec/ frame x 20-30 min

In the second phase, the renal phase, time-to-peak uptake is typically

between 2 and 4 minutes.

The renal phase is the most sensitive indicator of renal dysfunction.

Excretory phase: 1-minute images are taken for 30 minutes.

Furosemide 0.5 mg/kg is administered when maximum collecting system
activity is visualized.

The T1/2 is the time it takes for collecting system activity to decrease by 50%
from that at the time of diuretic administration.

This is highly technician dependent because the diuretic must be given when
the collecting system is displaying maximum activity.
• Normal < 10 min
• Obstructe d > 20 min
• Indeterminate 10 - 20 min
Dilated but unobstructed renal pelvis
Low-grade obstruction
THANK YOU