MAG3-F0 scintigraphy in decision making for emergency intervention in renal colic after helical CT positive for a urolith.
(17/140)
Patients with renal colic are evaluated with clinical, laboratory, and imaging methods for stratification for emergency decompression, medical treatment, or discharge and follow up. The current standard practice is heavily based on unenhanced helical CT for detecting uroliths. However, the presence of a urolith does not necessarily mean that the kidney is obstructed and requires emergency decompression. In this study, technetium-mercaptoacetyltriglycine (MAG3) diuretic scintirenography was used to detect obstruction in patients with renal colic. The contribution of this test to patient management after positive findings from helical CT was also studied. METHODS: Diagnostic criteria were established on the basis of previous experience with 60 patients who had renal colic and had undergone radiography of the kidneys, ureters, and urinary bladder (KUB) and diuretic Tc-MAG3 scintirenography and were followed up to correlate scintigraphic findings with clinical outcome. Subsequently, 80 patients with renal colic underwent scintigraphy within 12 h of presentation in the emergency room, after abdominal helical CT showed findings positive for calculus and suggestive of obstruction. After therapeutic oral or intravenous hydration and analgesics, diuretic dynamic renal scintigraphy (flow, function, delayed imaging) was performed after intravenous injections of 10 mCi (370 MBq) 99mTc-MAG3 and 40 mg furosemide (at zero time, or F0). Results were available soon after completion of the study and were considered in patient management. Four characteristic patterns of scintirenography, essential in patient stratification and treatment, had been standardized and were used for interpretation of the studies: the unobstructed kidney; the partially obstructed kidney, proximally or distally obstructed, with mild to severe obstruction and impairment of function; the totally obstructed kidney, with arrested renal function; and the unobstructed but dysfunctioning kidney after decompression, or stunned kidney. RESULTS: Among the 80 patients with positive helical CT findings, 56.5% were found to have obstruction by scintigraphy (32.5% partially, 24% completely); the remaining 43.5% did not have obstruction (21% without an indication of recent obstruction and 22.5% with stunned kidneys after spontaneous decompression). Occasionally, findings of preexistent urine extravasation or infection were present. Patients who, by scintigraphy, never had obstruction or had experienced spontaneous decompression did not require admission or emergency intervention; those with complete or severe obstruction required admission and decompression for relief of pain or restoration of function, whereas those with mild obstruction were treated variably with forced fluids, analgesics, or, less frequently, elective surgery. Outcome information from clinical examination, imaging, and interventional findings indicated that this stratification was successful. The test caused no side effects. CONCLUSION: For renal colic, clinical selection, KUB radiography, and even positive helical CT findings were all found to have a low positive predictive value for obstruction (in this study, 35%, 32%, and 56% respectively). Anatomic studies, including helical CT, should be followed by diuretic MAG3-F0 scintirenography to diagnose and quantify or exclude obstruction, detect spontaneous decompression, and appropriately stratify patients for emergency intervention, observation and medical therapy, or further work-up and discharge with referral to the clinic. (+info)
Evaluation of renal function with 99mTc-MAG3 using semiautomated regions of interest.
(18/140)
The need to draw regions of interest (ROIs) manually may reduce the convenience and reliability of estimating renal function from renal scintigraphy. We developed a semiautomated method to define ROIs for renal scintigraphy with 99mTc-mercaptoacetyltriglycine (MAG3) and evaluated the clinical applicability of the method to the estimation of renal function by camera-based methods. METHODS: Dynamic renal scintigraphy with 99mTc-MAG3 was performed on 21 patients. An operator placed a large rectangular ROI over each kidney, a circular ROI within the liver, and a rectangular ROI between the kidneys. Using these ROIs, semiautomated renal ROIs were determined on the basis of the temporal changes in counts, in addition to the absolute counts, and a subrenal background ROI was automatically assigned for each renal ROI. Background-subtracted renograms were generated using these renal and subrenal ROIs, and renogram parameters were derived from the slope of the renogram and the area under the renogram. Clearance was calculated using the renogram parameters and equations determined previously with manual ROIs and correlated with clearance measured by a single-sample method. The relative function of the right kidney determined by the semiautomated method was compared with that determined by the manual method. Data processing was performed independently by another operator to assess interoperator reproducibility. RESULTS: ROIs defined by the semiautomated method were visually judged to be acceptable for clinical use in all patients with a wide range of renal function. Clearance was successfully predicted with the semiautomated ROIs (r = 0.968 using the slope of the renogram; r = 0.934 using the area under the renogram), and relative function calculated with the semiautomated ROIs was almost identical to that calculated with manual ROIs. There was almost complete concordance in absolute and relative function between the two operators. CONCLUSION: The semiautomated method can define ROIs for 99mTc-MAG3 renal scintigraphy with limited operator intervention. Camera-based methods using the semiautomated ROIs allow estimation of renal function with high accuracy and little interoperator variability and are suggested to be suitable for clinical use. (+info)
Diuretic MAG3 scintigraphy (F0) in acute pyelonephritis: regional parenchymal dysfunction and comparison with DMSA.
(19/140)
99mTc-DMSA late static planar imaging or SPECT is being used for the investigation of focal acute pyelonephritis (APN), especially in children with urinary tract infection (UTI). Diuretic 99mTc-mercaptoacetyltriglycine (MAG3) dynamic scintirenography has been applied in the evaluation of kidney function and structure, frequently to exclude obstruction. However, in children and adults with a clinical picture of APN, diuretic MAG3 scintigraphy with zero time injection of furosemide (MAG3-F0) was observed to display focal parenchymal abnormalities; regional dysfunction (focal parenchymal decrease in early uptake; slow filling in and prolonged late retention of activity); or, less frequently, fixed defects. This observation was further studied both retrospectively and prospectively, and its sensitivity and specificity for APN were compared with those of dimercaptosuccinic acid (DMSA). METHODS: In the retrospective study, for 36 children with UTI and regional parenchymal findings on MAG3-F(0), data were reviewed, analyzed, and compared with the results of concurrent DMSA studies. In the prospective study, for 57 children with clinical and laboratory findings suggestive of APN, the 2 radiopharmaceuticals were used for imaging sequentially and the results of the 2 studies were compared. The criteria for abnormal findings compatible with the diagnosis of APN were, for MAG3-F(0), regional parenchymal dysfunction and fixed focal defects and, for DMSA, focal defects without parenchymal loss. RESULTS: In all groups of patients, most abnormal MAG3-F(0) studies (80%) showed regional parenchymal dysfunction, but in some (20%) a fixed defect was found. Compared with DMSA and when both regional dysfunction and focal defects were considered, MAG3-F(0) was as sensitive as DMSA. Some patients had only MAG3-F(0) abnormalities, suggesting a slightly lower specificity for MAG3-F(0) compared with DMSA (86%); this finding needs further study, because it also raises questions about the sensitivity of DMSA, considering that only a small percentage of patients with clinically suggestive findings had abnormal study findings. In most patients with fixed defects on both DMSA and MAG3-F(0), follow-up studies showed no resolution, suggesting that a fixed defect on MAG3-F(0) may indicate either more severe APN or preexistent scars and that regional dysfunction may be a sign more specific for APN and prognostic of potential recovery. In addition, a pattern more specific for a scar--a fixed defect with a dilated regional calyx--was seen on follow-up MAG3-F(0). CONCLUSION: A fast (25-min) planar dynamic MAG3-F(0) study was found to be as sensitive at depicting focal parenchymal abnormalities in APN as was the 3- to 4-h DMSA routine procedure. The sensitivity and specificity of both studies need further evaluation. (+info)
Effect of protein binding on renal extraction of 131I-OIH and 99mTc-labeled tubular agents.
(20/140)
The clearance of 99mTc-mercaptoacetyltriglycine (MAG3) is less than the clearances of o-131I-iodohippurate (OIH) and 99mTc-labeled DD- and LL-ethylenedicysteine (EC). This difference could be associated with the lower affinity of MAG3 for the tubular transport receptor, but MAG3 is more highly protein bound than OIH and the EC isomers; protein binding could also be an important factor governing tubular extraction. To separate the effects of protein binding from tubular receptor affinity, the extraction fractions (EFs) of MAG3, OIH, and the DD, LL, and DL isomers of 99mTc-EC were measured in an isolated perfused rat kidney model using a protein-free perfusate and perfusates containing bovine serum albumin. METHODS: The right kidney was removed from the rat and perfused with modified Krebs-Henseleit buffers containing 7.5 or 2.5 g/dL bovine serum albumin or a protein-free perfusate. OIH was coinjected into the renal artery with each of the 99mTc-tracers. Protein binding was measured in each of the perfusates, and the venous outflow was collected to determine the EF. RESULTS: The protein binding of MAG3 in the albumin perfusates ranged from 87% to 95%, significantly higher than the 20%-34% range of protein binding observed with the three EC complexes (P < 0.05). In the 2.5 g/dL albumin perfusate, the EF of MAG3 was 44%, significantly less than the 57%-77% EF of the three EC complexes; in the 7.5 g/dL perfusate, the MAG3 EF fell to 18% versus 39%-45% for the EC complexes (P < 0.05). However, in the protein-free perfusate, the EF of MAG3 was 64%, equal to or higher than the 46%-62% EF of the three EC complexes. CONCLUSION: Protein binding modulates the tubular extraction of renal tracers. Protein binding and receptor affinity must be considered in the design of future renal radiopharmaceuticals as well as radiopharmaceuticals targeting other receptors. (+info)
Renal cortical scintigraphy and diuresis renography in infants and children.
(21/140)
Renal scintigraphy is performed frequently in infants and children. Renal cortical scintigraphy using 99mTc dimercaptosuccinic acid is predominantly performed to assess the renal sequelae of urinary tract infection. It is most commonly performed for the evaluation of chronic renal scars, although it is also undertaken in the assessment of acute pyelonephritis. Diuresis renography using 99mTc mercaptoacetyltriglycine is of great use in the evaluation of renal tract obstruction, which may occur at a variety of levels, but most commonly occurs at the ureteropelvic junction. Consensus statements have been formulated in an attempt to standardize methods of performing these investigations. However, several areas of controversy exist in the performance of these studies, and these are outlined. Radionuclide cystography and renal function estimation using clearance calculations are not covered in this article. (+info)
Increased dietary salt accelerates chronic allograft nephropathy in rats.
(22/140)
BACKGROUND: Chronic allograft nephropathy (CAN), a major problem in renal transplantation, is related to both alloantigen-dependent and -independent processes. Because dietary salt intake modulated glomerular production of transforming growth factor-beta, which has been shown to play an important role in CAN, we hypothesized that dietary salt would directly enhance renal injury in a rodent model of CAN. METHODS: Dietary NaCl was increased from 1.0% (normal) to 8.0% in a group of Fisher/Lewis rats 25 days following orthotopic renal transplantation and was continued until 16 weeks after transplantation. RESULTS: Blood pressure, which was recorded using radiotelemetry in the first eight-weeks post-transplantation, did not differ between the groups, but allograft recipients on the 8.0% NaCl diet rapidly demonstrated increased urinary albumin excretion. Renal function determined by dynamic functional imaging was worse in allograft recipients on the 8.0% NaCl diet by six weeks following transplantation. Histologic examination at 16 weeks confirmed a significant increase in allograft damage in the 8.0% NaCl group compared with allografts from rats on 1.0% NaCl diet. These findings included glomerulosclerosis and tubulointerstitial injury that consisted of fibrosis, tubular atrophy and dilation, intratubular casts, and tubular epithelial cell damage. Small arteries and arterioles did not show evidence of damage from hypertension or other abnormality. CONCLUSIONS: In this model of CAN, renal allograft dysfunction preceded hypertension and was accelerated significantly by an increase in dietary salt. (+info)
Reconstruction of dynamic renal tomographic data acquired by slow rotation.
(23/140)
Nuclear medicine renal studies can be performed using slow-rotation SPECT, but reconstruction of such data is largely underdetermined. METHODS: A new method of reconstruction of data acquired using slow camera rotations was developed. In this method we used a factor model of the data in which the factors and factor coefficients were determined by modeling their relationship directly with the projection measurements. This was done by solving a least-squares problem that fits the projections of factors and factor coefficients to the projection data with nonnegativity constraints imposed on the solution. The method was tested on computer simulations and applied to experimental renal (99m)Tc-mercaptoacetyltriglycine canine and patient studies. RESULTS: Computer simulations showed that the extracted time-activity curves of kidneys agreed well with the simulated curves for data with noise levels similar to those in the experimental studies. In the canine study, the method showed that >2 factors were necessary to adequately reproduce the kinetics of the kidney. In the patient study, the method was able to extract separate factors that correspond to the kidney cortex and the kidney pelvis. CONCLUSION: The computer simulation, the canine study, and the patient study all show that reconstructions of the data obtained with 1 detector displayed artifacts, whereas reconstructions of the data obtained with 2 and 3 detectors were free of artifacts. Computer simulations showed that the method gives accurate results that allow quantitation. (+info)
Normalized residual activity: usual values and robustness of the method.
(24/140)
The objectives of this study were 2-fold: first, to investigate the robustness of the normalized residual activity (NORA), a parameter that has recently been proposed for the estimation of renal emptying during renography; and second, to define the usual values of NORA in 2 categories of kidneys-those with a normal renogram and those that are dilated but definitely unobstructed. METHODS: NORA was defined as the renal activity at a given moment (end of renogram, end of furosemide acquisition, image after micturition) divided by the renal activity between 1 and 2 min. Two variables that might influence the results of NORA were evaluated: the choice of background correction, and an error in the estimation of the 1- to 2-min renal activity. To estimate the values of NORA in usual clinical conditions, 2 sets of data were analyzed: normal kidneys with a normal renogram pattern, and dilated but definitely unobstructed kidneys. RESULTS: Using a perirenal or a subrenal background correction, NORA was, on average, 67% or 83%, respectively, of the value obtained without background correction. The use of a renal activity of 1 min 20 s to 2 min 20 s instead of a 1- to 2-min activity resulted in a systematic 10%-15% underestimation of NORA. The 90th percentile values of NORA were, in the normal group, 0.70 at 20 min, 0.23 at the end of the furosemide test, and 0.10 after micturition. In the kidneys that had undergone surgery, the 90th percentile values were 3.92 at 20 min, 2.91 at the end of the furosemide test, and 1.99 after micturition. A good correlation was observed between NORA and output efficiency. CONCLUSION: If adequately standardized, NORA is a robust and simple parameter that allows evaluation of renal emptying at any time of the acquisition. One should be aware of the fact that high NORA values, corresponding to poor renal emptying, may be observed in the operated unobstructed kidneys, even after micturition. (+info)