99mTc-MAG3 Diuretic renography in obstructive uropathy in

adults: a comparison between F-15

and a new procedure F+10SP (Seated Position)

Tartaglione G

Nuclear Medicine

CRISTO RE Hospital

Rome, Italy

ContentContent

01 Background

02 Early Furosemide

03 Aim of the study

04 Procedure

05 Material and methods

06 Data processing

07 Clinical cases (1-5)

08 Results

09 Conclusion

2

BackgroundBackground

• Diuretic Renography (F+20) was developed by O'Reilly PH in 1978 to distinguish between the dilated

non obstructed and the obstructed upper urinary tract (partial urinary tract obstruction, effectiveness

of stenting, effectiveness of obstruction correcting surgery)

• Currently the Guidelines exist only for to interpret the results of diuretic renography in children, that

recommend:

Supine position to minimise renal depth difference and assist in keeping movement to a minimum;

Four Timing of administration of diuretic:

F+20F+20 : Furosemide is injected 20 minutes after the injection of tracer

FF––15 15 : Furosemide is injected 15 minutes prior to the tracer

F0F0 : Furosemide is injected at the beginning of the study

F+2F+2 : In some departments using the Patlak/Rutland plot, the Furosemide is given 2

minutes after the injection of tracer.

• There is no evidence at the present time to suggest that any one of the above timings is "better" than

the other (EAMN Guidelines, 2000)

EANM GUIDELINES FOR STANDARD AND DIURETIC RENOGRAM IN CHILDREN

Paediatric Committee of the European Association of Nuclear Medicine, 2000 3

EarlyEarly FurosemideFurosemide

The Disadvantages

• The tendency nowadays is to use F0 protocol but this has the disadvantage like the F-15 of not

providing information about the baseline state

• The early furosemide (F-15, F0) has other potential pitfalls it understimates split renal function, and

accelerating transit can make the use of the Patlak-Rutland method difficult

• When the patient is supine urine flow may be slow, and the renogram curve will show a rising

pattern, mimicking obstruction.

• If the test is done supine, in case of prolonged transit, then further images should be obtained

erect. (Prigent A. & Piepsz A, Functional Imaging in Nephro-Urology, 2006).

• Therefore supine positioning is recommended over erect (seated) positioning. In obstructive renal

pathology, acquisition in the erect position can be preferable because of the hydrostatic pressure.

More realistic results will be achieved. (EANM, Dynamic renal imaging in obstructive renal

pathology, A Technologist’s Guide, 2009)

ISCORN Consensus on renal transit time measurements

Semin Nucl Med 38:82-102 2008 4

AimAim of the of the studystudy

5

was to compare, in the same group of adult patients, two 99mTc-MAG3 diuretic renogram

procedures for diagnosis of upper urinary tracts obstruction:

For the first procedure we used the protocol F-15:

400-500 mL of water were given 30 minutes before the test; 40 mg of Furosemide were

injected IV 15 minutes before radionuclide administration, after voiding the tracer was

injected and a renogram was acquired with patient in supine position;

For the second we proposed a new procedure F+10SP:

at 0’ the tracer was injected and a renogram started in Seated Position,

400-500 mL of water were given to drink at 5th minute after tracer

injection, and 20 mg of Furosemide were given IV at 10th minute after

radionuclide administration (during acquisition).

5 6

Procedure Procedure F+10SP Seated Position 99mTc- MAG3

Timeline

0' 0' 5' 5' 10' 10' 2020’’

Tracer Inj. Drink Water Furosemide 20 mg Stop 6

Material & Material & MethodsMethods

• 36 adult patients (20 f, 16 m) yrs 37 (range: 18-71), with unilateral (29) or bilateral (7)

hydronephrosis demonstrated by ultrasound

• They underwent consecutively two diuretic renograms: F-15 & F+10SP separated by a one

week time interval, using a GE-Infinia-Xeleris gamma camera with a single-head flexibility

• All patients were normally hydrated and without diuretics or ACE-inhibitors in the 48 hours

before study

• The injected activities were: 100-150 MBq of 99mTc- MAG3, volume 0.3 mL

• We acquired:

Dinamically: 60 frames of 2”, 108 frames 10”, matrix 128x128, zoom 1, post view

Two Static images: Pre-Voiding and Post-Voiding after walking for few minutes and changing

position (preset-time 60”, matrix 128x128)

• Another test F+10SP was performed to check the therapy or as follow-up on average 1 year

after inclusion in the study (in 21 out of 36 patients)

• Ethical approval from an appropriate Committee and consent was obtained from participants

to the study.

7

Data ProcessingData Processing

• A comparison of renograms was based on the:

– Visual assessment of renograms

– Early Summed Uptake image 60”-120” (Supine image vs Seated)

– Tmax - Time to Peak (NV <6 mins)

– Diuretic T1/2 – the time that elapsed between the administration of the diuretic and

the diuretic T1/2

– 20min/Peak Ratio - the ratio between the average activity of the curves at 19 to 20

minutes and the peak activity (NV <0.25)

– Uptake % - Split renal function (NV = 0.50 +/- 0.10)

– ERPF mL/min (using modified Schlegel, and modified Gates methods)

– Pre-Voiding and Post-Voiding images after changing position and walking for few

mins

– Injection site image (quality control)

• The results were classified as: Non-obstructive, (Normal [Tmax <6mins], or Dilation

without obstruction [Tmax >6 mins] only for F+10SP), Obstruction, Equivocal and Not

Applicable.

• Cohen’s Kappa were calculated to compare the results of the two tests

8

9

Supine Seated PV

F+10SPF+10SP F+10SP FU (1 F+10SP FU (1 yearyear))

63.35

0.14

2.25

4.18

F+10SP

LEFT

36.65

0.61

138.48

11.35

F+10SP

RIGHT

61.13

0.13

2.75

3.87

F+10SP

LEFT FU

0.130.760.1920min/Peak

Ratio

3.75NA4.63Diuretic T1/2

Minutes

38.8736.6563.35Uptake %

1.81

F-15

LEFT

19.81

F-15

RIGHT

9.21

F+10SP

RIGHT

FU

Time to Peak

MSA, 22 ys,

female

R R

FF--1515

FF--1515

ClinicalClinical case 1case 1

MSA, 22 ys, female

Supine Seated PV

9 10

R R

Seated Supine PV

FF--1515 F+10SPF+10SP

BMC, 46 ys, female

F+10SP FU (1 F+10SP FU (1 yearyear))

66.15

0.14

3.42

6.68

F+10SP

LEFT

33.85

0.33

9.67

9.35

F+10SP

RIGHT

61.32

0.10

2.25

7.98

F+10SP

LEFT FU

0.130.340.1620min/Peak

Ratio

4.0818.585.60Diuretic T1/2

Minutes

38.6855.5344.47Uptake %

1.66

F-15

LEFT

2.59

F-15

RIGHT

8.65

F+10SP

RIGHT FU

Time to Peak

BMC, 46 ys,

female

F+10SPF+10SP

ClinicalClinical case 2case 2

10

11

FF--1515 F+10SPF+10SP F+10SP FU (1 F+10SP FU (1 yearyear))

33,44

0,35

8,17

19,85

F+10SP

LEFT

66,56

0,18

3,75

3,68

F+10SP

RIGHT

44,66

0,11

2,17

14,56

F+10SP

LEFT

FU

0,140,210,5520min/Peak

Ratio

3,425,8367,14Diuretic T1/2

Minutes

55,3468,9331,07Uptake %

11,06

F-15 LEFT

2,22

F-15

RIGHT

1,46

F+10SP

RIGHT

FU

Time to Peak

FV, 29 ys,

female

F+10SP FU (1 F+10SP FU (1 yearyear))

Seated Supine PV

FV, 29 ys, female

ClinicalClinical case 3case 3

11

FF--1515 F+10SPF+10SPFF--1515 F+10SPF+10SPFF--1515 F+10SPF+10SP

R R

ClinicalClinical case 4case 4

FF--1515 F+10SPF+10SP

12FF--1515

Supine Seated PV

13

F+10SPF+10SPFF--1515

RR

0.150.170.240.2620min/Peak

Ratio

3.756.007.007.33Diuretic T1/2

Minutes

22.1977.8147.8252.08Uptake %

2.56

F-15

LEFT

2.90

F-15

RIGHT

2.78

F+10SP

LEFT

4.11

F+10SP

RIGHT

Tmax

SN, 35 ys,

female

Summed Uptake Seated Supine

Image 60”-120” Position Post Voiding

SN, 35 ys, female

R

ClinicalClinical case 5case 5

13F+10SPF+10SP 14

0.27 (0.14)

10.51 (9.03)

4.07 (3.43)

FF--1515Mean (SD)

p = 0.0010.23 (0.13)20MIN/PEAK Ratio

(NV <0.25)

NS6.25 (17.1)DIURETIC T1/2

NS7.61 (3.39)Time to Peak

(NV <6 mins)

P valueF+10SPF+10SP

Mean (SD)Index

ResultsResults

722112039Total

00000Not applicable **

101 (9.1)00Equivocal

252 (100.0)3 (27.3)20 (100.0)0Obstruction

2206 (54.5)016 (41.0)Dilation without

obstruction *

2401 (9.1)023 (58.9)Normal

No. (%)No. (%)No. (%)No. (%)

**Not

applicableEquivocalObstruction

Non

ObstructiveTotal

FF--1515

F+10SPF+10SP

ResultsResults ResultsResults

• Side effects: 13 bladder filling, 1 hypotension,

3 renal colic, and 5 disruption because voiding;

• Tmax value was <3 mins in 37 out of 72 renal units.

This should be taken into account when calculating the

split renal function, favouring integral method on the

basis of the 1-2 min background-corrected renal activity

(Donoso & Piepsz)

• N/A in 2 kidneys due to insufficient renal function

• No Side effects are reported;

• Tmax value was <3 mins in 4 out of 72 renal units;

• F+10SP distinguished between 23 normal (Tmax <6

mins) and 16 dilation without obstruction (Tmax >6

mins, Ratio <0.25) providing information about the

Baseline state

SP showed nephroptosis in 16 kidneys and ectopia in 1

(10 out of 17 kidneys were obstructed)

16Seated Supine PV

FF--1515 F+10SPF+10SP

no ob s truc tion

39

e q uiv oc al

11

ob s truc tio n

20

N/A

2 normal

24

equiv ocal

1

obs truc tion

25

dilation

22

ConclusionsConclusions

The new procedure F+10SP:

• It provides information about the baseline state distinguishing between dilation without

obstruction and normal cases

• it may reduce the equivocal results of F-15 for diuresis renography avoiding the

physiological slow drainage typical of supine position, and giving significance to the

drainage index like as 20min/Peak Ratio (normal value <0.25)

• It has a better compliance, no side effects are reported (this procedure is safe and well

tolerated, thank to a better timing and a reduced dose of furosemide)

• it may reduce incidence of not applicable tests F-15, due to insufficient renal function

(uptake % <10%)

• it can make clear the influence of the nephroptosis on the drainage phase

• it is time saving, cost effective and it seems to be a more reliable and easier tool in the

management of upper urinary tracts obstruction in Adults.

17

Спасибо

Thank You for your attention

gtartaglione@hotmail.com