LOGO

The Urinary Tract

1 1
 Objectives LOGO

Master the normal and abnormal renogram

curve.

How to diagnose the renal function on renal

dynamic imaging

2
 LOGO

Since the early 1950s, radionuclides have been

used to evaluate renal function. Early studies
using external probe detector systems produced
no images, only time-activity histograms that
showed the uptake and clearance of the renal
radiotracer. These nonimaging studies did not
permit evaluation of renal blood flow or
differentiation of renal parenchyma from
collecting system.

3
 LOGO

Dynamic renal imaging provides sophisticated

examinations of renal blood flow, function,
anatomy, and collecting system integrity.

4
 LOGO

Indications for renal scintigraphy include

differentiating obstructive from nonobstructive
hydronephrosis, assessing the significance of
renal artery stenosis, searching for
postoperative leaks, and the evaluation of
infection and scarring. Quantifying differential
function and assessing viability is useful in the
evaluation of complications that can occur
after surgery or trauma.

5
 LOGO

The ability to quantify by effective renal

plasma flow (ERPF) and glomerular
filtration
rate (GFR) can provide a better
measurement
of function than estimations based on
serum
creatinine.

6
 LOGO

Over the years, many

radiopharmacueticals have been
developed to assess different
aspects of renal function based on
binding
characteristics and clearance pathways.

7
 LOGO

RENAL ANATOMY AND PHYSIOLOGY

8
 RENAL ANATOMY AND PHYSIOLOGY LOGO

The kidneys are paired, bean-shaped

organs that measure 9 to 11 cm in
length, extend from the first to third
lumbar(L1 to L3) vertebral bodies. The
right kidney is often lower than the left.

9
 RENAL ANATOMY AND PHYSIOLOGY LOGO

The outer cortex contains

the glomeruli and proximal
convoluted tubules. The
inner layer, or medulla,
contains renal pyramids
made up of distal tubules
and the loops of Henle.

10
 RENAL ANATOMY AND PHYSIOLOGY LOGO

At the apex of the

pyramids, papillae drain
into the renal calyces.
Cortical tissue between
the pyramids is known
as the columns of
Bertin.

11
 LOGO

The renal artery and vein

enter and leave at the
hilus. The interlobar
branches of the renal
artery divide and become
the arcuate arteries,
which give rise to the
straight arteries, from
which arise the afferent
arterioles that feed the
glomerular tuft.

12
 RENAL ANATOMY AND PHYSIOLOGY LOGO

The nephron consists of afferent

vessels leading to the tuft of
capillaries in the glomerulus, the
glomerulus itself, and efferent
vessels. Bowman capsule
surrounds the glomerulus and
connects to the proximal and
distal renal tubules and loops of
Henle. Each kidney contains more
than 1 million of these basic
functional units of the kidney–
the nephron.

13
 What the function of the kidneys? LOGO

The kidneys are responsible for regulating

water and electrolyte balance, excreting
waste, secreting hormones ( renin,
erythropoietin), and activating vitamin D.

14
 LOGO

Normally, the kidneys receive 20% of cardiac

output, with renal plasma flow( RPF) averaging
600mL/min. The kidneys clear the plasma flow
and body of waste products.

15
 LOGO

Plasma clearance occurs by glomerular filtration

and tubular secretion. The actual extraction
possible clinically is less than 100%, the term
effective renal plasma flow (ERPF) is used to
describe the measurement.

16
 LOGO

Approximately 20% of RPF is filtered through

the semipermeable membrane of the glomerulus.

The resulting ultrafiltrate, consisting of water

and crystalloids but no colloids or cells, enters
into the renal tubule. Nephrologists use inulin
as a standard measure of the glomerular
filtration rate (GFR) , since it is entirely
filtered through the glomerulus.

17
 LOGO

The remaining 80% of plasma not filtered

enters the peritubular fluid and is actively
secreted by the tubular epithelial cells
into the renal tubules.

18
 LOGO

19 19
 LOGO

As urine passes along the

tubule, the filtrate is
concentrated and essential
substance are conserved.
The tubulary epithelium
actively reabsorbs water
and selected substance
( glucose, sodium, amino
acids ) into the blood.

20
 LOGO

The renal tubules empty formed urine

into the calyces through the papillae of
the medullary pyramids. From there the
urine passes to the renal pelvis, ureter
into the bladder.

21
 LOGO

Renal scan

22
 LOGO

Mechanism
The principle of renogram or renal scan is
that metabolites useless materials first
filtrated by glomeruli or secreted by renal
tubules and then passed outside the body.

23
 Renal Radiopharmaceuticals LOGO

Numerous radiopharmaceuticals have been

developed over the years that can assess
renal function. Renal radiopharmaceuticals
are classified by their uptake and clearance
mechanisms as agents for glomerular
filtration, tubular secretion, or cortical
binding.

24
 Renal Radiopharmaceuticals LOGO

Mechanism of Uptake for Renal Scintigraphy

Imaging Agents
Clearance Agent (%)

Glomerular filtration Tc-99m DTPA 100

Tubular secretion Tc-99m MAG3 100

Tubular secretion and I-131 hippuran 80 tubular

Glomerular filtration 20 filtered

Cortical binding Tc-99m DMSA 40-50

25
 LOGO

26 26
 LOGO

The clinically applications of Tc-99m DTPA

and Tc-99 DMSA are often interchangeable.
Because they can both examine flow and
renal function. However, only Tc-99m DTPA
can be used to calculate GFR.

27
 LOGO

Tc-99m DTPA is a versatile renal imaging

agent that can help evaluate prerenal blood
flow, renal parenchymal function, and
postrenal collecting system .

28
 Pharmacokinetics of Tc-99m DTPA LOGO

Following intravenous injection, normal

peak cortical uptake occurs by 3 to 4
minutes. By 5 minutes, the collecting
system is seen; the bladder is typically
visualized by 10 to 15 minutes.

29
 Pharmacokinetics of Tc-99m DTPA LOGO

Dynamic Renography

30
Pharmacokinetics of Tc-99m DTPA LOGO

Dynamic functional studies

are generally acquired in two
parts. Renal blood flow
is assessed in the first part of
the
radiopharmaceutical bolus to
the kidney.
31 Then, over the next 25 to 30
 Method LOGO

Patient Preparation

Patients should be well hydrated before the

study. While blood flow, radiopharmaceutical
uptake, or functional calculations are not
altered, excretion and washout can be delayed
by dehydration, simulating obstruction or poor
function.

32
 LOGO

It is important to document all medications

the patient has taken that may affect the
study, such as diuretics and blood pressure
medicines. Any known anatomic anomalies
and prior interventions are important factors
to consider in positioning and image interpretion.

33
 Method LOGO

Patient Positioning

A supine position is preferred because kidneys

are frequently mobile and can move to the ante-
rior pelvis when patients are upright. Patients
are placed so that the kidneys are closest to the
camera, with the camera posterior for normal
kidneys and anterior for transplants, pelvic
kidneys, and horseshoe kidneys.

34
 Image Acquisition LOGO

After a bolus injection of radiopharmaceutical,

the image acquisition begins when activity is
about to enter the abdominal aorta. Images are
acquired at a rate 1 to 3 seconds per frame for 60
seconds to assess renal perfusion.

35
 Image Acquistion LOGO

Then images are acquired at 60 seconds per

frame for 20 to 30 minutes to evaluate
parenchymal radiotracer uptake and clearance.

36
 Computer Processing of Renal Studies LOGO

The uptake and clearance of

radiopharmaceuticals is a dynamic process.
Mentally integrating all the information in the
many images of a renal scan is challenging,
even for experienced clinicians.

37
 Flow (perfusion) phase LOGO
A region of interests is drawn around each
kidney and the closest major artery (aorta for
native kidneys, iliac artery for transplanted
kidneys) on the initial 60-second portion of the
study.

38
 Dynamic Functional Imaging Phase LOGO

A region of interest (ROI) around each kidney.

The selection of kidney ROI depends on the
information needed. Whole-kidney regions can be
used if the collecting system clears promptly.

39
 LOGO

By placing appropriate regions of interest (ROI)

over the kidneys, various parameters of renal
function can be derived. These include
differential renal function measurements,
renogram curves generated from ROIs placed
around the entire kidney, renogram curves
generated from ROIs placed over the cortex of
the kindey, and pelvic emptying curves.

40
1. Whole kidney versus cortical regions of interest.
LOGO

The whole kidney region of interest (ROI) consists of

an ROI placed around the whole kidney including
the renal pelvis. Quantitative values generated using
this ROI will be affected by retention of tracer in the
kidney and collecting system; retention may be due
to pathological states such as diabetic nephropathy
or obstruction or may occur in non-pathological
states such as a non-obstructed collecting system
or mild dehydration.

41
To obtain a better assessment of parenchymal function,
cortical or parenchymal regions of interest may be assigned
LOGO
over the renal cortex (parenchyma) that exclude any activity
retained in the pelvis or calyces.
Cortical regions of interest often provide a better
assessment of renal function but have reduced counts
compared to whole kidney ROIs and are more susceptible to
artifact due to motion or reduced counts in a poorly
functioned kidney.

The activity
retained in the
left renal
pelvis should
be excluded.

42
 LOGO

Various methods of background

correction
have been employed using a 2-pixal-wide
region of interest. It may be placed
beneath
the kidneys, around the kidneys, or in a
crescent configuration lateral to the
region
of interest.

43
 LOGO

If 99mTc-DTPA is used, the GFR can be calculated.

After injection, the tracer is assumed to mix
rapidly in the blood leading to a uniform plasma
concentration. The tracer then diffuses out of the
plasma into the extracellular fluid (ECF) and
eventually the intravascular and extracellular
compartments reach equilibrium. The
concentration of tracer in the plasma declines
over time because of diffusion into the ECF and
renal excretion.

44
 LOGO

An imaging approach to measure GFR involves

placing ROIs over both kidneys and calculating
the uptake in the kidneys as a percentage of the
injected dose. A regression curve is used to
relate this percentage to GFR.

45
 Differential Function LOGO

Differential or split function is a universally

performed calculation. This calculation is
particularly useful because serum creatinine
may not identify unilateral lesions.

46
 Renogram LOGO

Computer-generated time-activity curves(

TACs ) provide a dynamic visual
presentation
of change in activity over the course of the
study.
Usually, separate time-activity curves are
drawn for the blood flow and dynamic
function portions of the study.

47
 LOGO

At any point in time, the renogram represents a

summation of uptake and excretion. Three phases
are normally seen in time-activity curves. These
include blood flow, cortical uptake, and clearance
phases.

48
 LOGO

Numerous values can be derived from time-

activity curves and are used to help track
functional changes.
These include peak activity, uptake slope, rate of
clearance, and percent clearance at 20
minutes.

49
 Time to peak (peak activity) LOGO

The time to the peak ( Tmax) of the renogram

curve is a useful measurement, particulary in the
evaluation of patients with suspected
renovascular hypertension. In general, the peak
should occur by 4min after injection, but retention
of the radiopharmaceutical in the renal calyces or
pelvis can alter the shape of the renogram and
affect the Tmax measurement.

50
 The normal renogram curve LOGO

The normal curve can be divided into 3 phases:

1. the blood flow phase, characterized by a sharp
rise (30 to 60 seconds);

51
2. the uptake phase, in which the TAC
LOGO
rises, but less sharply, because of cortical
accumulation of tracer (2 to 4 minutes
normal, longer with renal insufficiency);

The slope and

height of phase 2
reflects the
velocity and
amount of tracer
accumulating in
the kidney.

52
 LOGO

3. the excretory phase, in which the TAC

falls as a tracer leaves the cortex and
urinary collecting system.

53
 LOGO

The efficiency of uptake is reflected by the

slope of the ascending portion of the TAC and
by the time at which the peak counts of Tmax are
reached. The rate of disappearance of the tracer
from the kidney is an important indication of
tubular function and is expressed by T1/2.

54
 SIX TYPES OF ABNORMAL CURVE LOGO

1. Parabola type:
The curve rises slowly, gradually falls and Tmax
prolongs. It suggests the patients suffer from
mild renal insufficiency.

55
 LOGO

2. Low level prolonged type: Height of phase

1 is lowered, while phase 2 and 3 merged each
other. It indicates severe renal injury.

56
 LOGO

3. Low level descending type: The curve

shows significant low phase 1 with gradual
down slope, without phase 2 and 3.
such patients usually have nonfunction
kidney.

57
 LOGO

4. Acute rising type: Phase 1 is normal,

phase 2 is continued uprising, but phase 3 is
disappeared.
In this condition, it means urinary obstruction
or acute renal failure.

58
 LOGO

5. High level prolonged type:

Phase 1 is normal too, and phase 2 rises
gradually. This curve always occurs in
urinary obstruction with renal insufficiency.

59
 LOGO

6. Stepwise drop type: Phase 1 and 2 are

normal, but phase 3 drops step by step. It is
seen in spasmodic ureter.

60
 Pharmacokinetics of Tc-99m DTPA LOGO

Interpretation

61
 Flow Phase
LOGO

Blood flow to the kidneys is normally seen

immediately after flow appears in the
adjacent artery within 4 to 6 seconds.

62
 It is important to assess the quality of the injection
bolus, because delayed renal visualization may be
artifactual, as a result of suboptimal injection technique.LOGO
Any significant asymmetry in tracer flow suggests
decreased renal perfusion to that side.

A. Sequential 2-second frames show moderately delayed and decreased

blood flow to the right kidney. B. Sixty-second time activity curves
confirm the imaging findings. Initial upslope of the right kidney is
delayed compared with the aorta and left kidney.
63
 LOGO

Splenic perfusion must not be confused

with left renal perfusion, as in a patient
with no left renal function because of
disease or surgery.

64
 Cortical Function Phase LOGO

Normal kidneys accumulate radiopharmaceutical

in the parenchymal tissue in the first 1 to 3
minutes. The cortex appears homogeneous. The
calyces and renal pelvis are either not seen in
this initial phase.

65
 LOGO

If decreased function is present on one side, the

rate of uptake and function are often delayed on
that side relative to the better functioning kidney.
This produces a “flip-flop” pattern; the poorly
functioning side initially has lower uptake, but the
cortical activity on later images is higher than on
the better functioning side, which has already
excreted the radiotracer. Cortical retention, or
delayed cortical washout, is a nonspecific finding,
occurring in acute and chromic renal failure.

66
 LOGO

Acute renal failure. Tc-99m DTPA shows slow uptake and clearance
With bilateral cortical retention. The time-activity curves show poor
Uptake
67 and clearance with a rising type .
 Clearance Phase LOGO

The calyces and pelvis usually begin filling by 3

minutes. Over the next 10 to 15 minutes,
activity in the kidney and the collecting system
decreases.

68
 LOGO

With good function, most of the radiotracer

clears into the bladder by the end of the
study. Lack of clearance or overlap of
the renal pelvis and calyces on the cortex
suggests hydronephrosis. Because areas
with
increased activity appear larger, caution
must be taken in diagnosing
hydronephrosis
on scintigraphic studies.

69
 LOGO

The normal ureter may or may not be seen,

depending on the urinary flow rate. Prolonged,
unchanging or increasing activity visualization
suggests ureteral dilation. The bladder must be
monitored as well.

70
 LOGO

Clinical applications of
renal scintigraphy

71
 LOGO

The clinical uses for renal scintigraphy are

numerous. Dynamic renal scintigraphy with
computer-derived TAC histograms permits
evaluation of blood flow, renal morphology
and size, parenchymal function, and
collecting system patency.

72
 LOGO

Individual or differential renal function is

routinely assessed for patients with
two kidneys. This information cannot
easily be obtained from any
nonradionuclide method.

73 73
Differential or split function is a universally
performed calculation. This calculation is LOGO

particularly useful because estimated GFR and

serum creatinine may not identify unilateral lesions.

A, Tc-99m DTPA images and time-activity curve (B) acquired shortly

after injury from a car accident show little function in the right kidney
74
(calculated at 6%).
 LOGO

Normal differential function ranges

from 40% to 60%.

75
 LOGO

Nuclear medicine studies are often ordered

for evaluating pediatric renal problems
because of the low radiation dose, lack of
toxicity, and valuable information regarding
renal function.

76
 LOGO
1.urinary tract obstruction
Obstruction can lead to recurrent infection,
diminished function, progressive loss of
nephrons, and parenchymal atrophy. Upper
urinary tract obstruction results in
backpressure from the pelvis onto the tubules
and vessels. Within hours of onset, renal blood
flow, glomerular filtration, and renal output
are decreased.

77
 LOGO

If a high-grade obstruction is corrected

promptly, function can completely recover. If
it is left uncorrected for more than a week,
only partial recovery is expected.

78
 LOGO

Ultrasound is a sensitive method of identifying

hydronephrosis but cannot reliably indicate
whether the dilation is due to mechanical
obstruction or merely nonobstructive
hydronephrosis (such as from reflux, primary
megaureter, or a previous obstruction that has
been relieved).

79
 LOGO

Retrograde pyelography and CT scans often can

identify the cause of an obstructed system
such as a ureteral calculus or tumor. However,
assessment of the residual function and the
effects of treatment using radionuclide imaging is
still often important.

80
 LOGO
Conventional radionuclide renography
show findings that overlap between
obstructed
and nonobstructed systems: delayed filling,
dilation, and decreased washout. The
addition of furosemide to the protocol
allows accurate identification of patients
affected by obstruction.

81
 LOGO

If mechanical obstruction is present, the

narrowed lumen prevents augmented
washout; prolonged retention of tracer is
seen and can be quantified on the time-
activity curves.

82
 LOGO

In a normal, nondilated kidney, the TAC rapidly

reaches a sharp peak and spontaneously clears
rapidly. Furosemide diuresis accelerates the rate
of radiotracer washout in a normal kidney.

83
 LOGO

In dilated but nonobstructed system may

initially look like a normal kidney with a steep
TAC uptake slope. However, sharp peak is not
seen, as the dilated system fills, the TAC may
show continued accumulation or a plateau 15 to
20 minutes after tracer injection.

84
 LOGO

After furosemide infusion, a nonobstructed

hydronephrotic kidney clears promptly as a
result of increased urine flow. An obstructed
system, on the other hand, will not respond to
the diuretic challenge; activity will continue to
accumulate or sometimes stays at a plateau.

85
 LOGO

86 86
 LOGO

2. Renovascular hypertension

87
 LOGO

When an arterial lesion causes significant vascular

renal artery stenosis (RAS), glomerular perfusion
pressure drops, causing the GFR to fall. If renal
blood flow remains low, the kidney will become
scarred and contracted with time.

88
 LOGO

Although more than 90% of patients with

hypertension have essential hypertension,
renovascular hypertension (RVH) is common
among patients who have a correctable cause.

89
 LOGO

RAS often can be diagnosed with color Doppler

ultersound, diagnostic CT and MRI. Not all
caese of RAS will cause RVH, and thus some
patients will show no response to angioplasty or
stenting. Therefore an ACE (angiotensin
converting enzyme) inhibition
renography or a captorpril scan is also indicated
on patients with an anatomical lesion, to
determine which cases will benefit from
correction of a stenotic lesion.

90
 The captopril renal scan is the most useful test
for detecting unilateral disease in patients withLOGO
GFR﹥ 30ml/min. An ordinary renal scan has a
false negative rate of 20-25%. The predictive
value of scanning can be increased by
performing a captopril-stimulated renal scan in
the patient with normal or minimally impaired
﹥
renal function who is not on an ACE inhibitor.

91
 LOGO

If the glomerular agent Tc-99m DTPA is used, the

TAC inhibitor-induced drop in GFR leads to a
marked drop in radiotracer filtration and
uptake. The most common pattern is an overall
drop in function seen as slower uptake and a
lower peak.

92
 LOGO

3.Etiology of renal failure

Renal scintigraphy can be
useful in the
evaluation of renal failure.
Prerenal,
renal, and postrenal causes
can be
93 diagnosed or excluded. Blood
 LOGO

94
 LOGO

Decreased perfusion to the kidneys,

unilateral or bilateral, may be seen with
renal artery stenosis, thrombosis, avulsion,
venous thrombosis, and renal infarction.

95
 LOGO

Approximate renal size, morphological

features, and differential renal function
are easily determined with scintigraphy.

96
 LOGO

Functional abnormalities of uptake and

clearance can be demonstrated with acute
and chronic renal disease. However, the
findings are not specific for etiology.

97
 LOGO

Renal scintigraphy is also used to determine

the functional significance of dilation seen on
other imaging modalities, for example,
whether surgical intervention is required.

98
 4. Renal transplant LOGO

Radionuclide scintigraphy has been widely used

evaluation
to evaluate renal allograft function. Radiotracer
techniques are noninvasive and are easily
repeated to clarify the evolving clinical findings.

99
 LOGO

Acute tubular necrosis (ATN) is an early

complication. ATN is characterized
scintigraphically by well-preserved perfusion
but poor renal function and decreased urine
excretion. These findings are usually seen on
renal scintingraphy performed within 24 hours
of surgery.

100
 LOGO

Hyperacute rejection is an other complications.

Although rarely seen, the scintigraphic
appearance of hyperacute rejection is absent
perfusion to the transplanted kidney and no
function.

101
 LOGO

A common complication, acute rejection typically

occurs 5 to 7 days after transplantation,
although it may occur at any time, usually during
the first 3 months. The scintigraphic hallmark
of acute rejection is decreased transplant
perfusion and poor function.

102
 LOGO

103
 Exercises LOGO
1. The left renogram curve is belong to ( ), it implies ( ) .
 A. Parabola type, mild renal insufficiency.
 B. Acute rising type, urinary obstruction.
 C. Low level prolonged type, severe damage.
 D. High level prolonged type, urinary obstruction
 with renal insufficiency.

104
 Exercises LOGO
 2. The renal renogram is belong to ( ), it implies ( ).

 A. Parabola type, mile renal insufficiency.
 B. Normal curve, normal function.
 C. Stepwise drop type, spasmodic ureter.
 D. Low level descending type, no function.

105
3. The left renogram curve is belong to ( ), it implies ( ).
LOGO
A. Parabola type, mild damage of the renal function.
B. Low level prolonged type, severe renal injury.
C. Stepwise drop type, severe renal injury.
D. Low level descending type, no function kindey.

106
4. The left renogram curve is belong to ( ), it implies ( )
A. Parabola type, mild renal insufficiency. LOGO
B. Acute rising type, urinary obstruction.
C. Low level prolonged type, severe damage.
D. High level prolonged type, urinary obstruction with
renal insufficiency.

107
 Questions
LOGO

1.Please describe the normal renogram.

2.How many kinds of abnormal renograms, please
describe them, respectively?
3.What’s the clinical application of dynamic renography
scan?

108