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Nuclear medicine in acute and chronic renal failure
Nuclear Medicine in Acute and Chronic Renal Failure Richard A. Sherman and K w a n g J. Byun The diagnostic value of renal scintiscans in patients w i t h acute or chronic renal failure has not been emphasized o t h e r than for the estimation of renal size. 13~10IH, eTgallium. ~ ' T c D T P A . glucoheptonate and DMSA all may be valuable in a v a r i e t y of specific settings. Acute renal failure due to acute tubular necrosis, hepatorenal syndrome, acute interstitial nephritis, cortical necrosis, renal artery embolism, or acute pyelonephritis may be recognized. Data useful
in t h e diagnosis and management of t h e patient w i t h obstructive or reflux nephropathy may be obtained. Radionuclide studies in patients w i t h chronic renal failure m a y help make apparent such causes as renal artery stenosis, chronic pyelonephritis or lymphomatous kidney infiltration. Future correlation of scanning results w i t h renal pathology promises to further expand nuclear m e d i c i n e ' s utility in t h e noninvasive diagnosis of renal disease.
ENERALLY recognized uses for nuclear G medicine in nephrology include the assessment of renal blood flow, glomerular filtration
(mean BUN 96 mg/dl, creatinine 7.6 mg/dl) and inadequate visualization with ~97Hg chloromerodrin, s While renal size was often inexplicably large despite chronic parenchymal disease, there was confirmation of this finding by high dose urography. Other reports confirm the value of 131l OIH in demonstrating renal size despite severe renal impairment.6-8 Renal concentration of OIH occurs with as little as 3% of normal function? Because of the excellent imaging characteristics of 99mTC,its various chelates are quite useful in renal failure. '~ This accounts for the superiority of 99mTCdiethylenetriamine pentaacetic acid (DTPA) over 197Hg chloromerodrin in imaging the failing kidney~ despite excretion of the former wholely by glomerular filtration and the progressive renal uptake with minimal excretion of the latter, lz-~4 Reba estimated that renal size could be determined with 99mTCDTPA in 75% of patients with BUN over 65 mg/dl.' In addition to the advantages of carrying the 99mTCmoiety, glucoheptonate (GH) and dimercaptosuccinic acid (DMSA) are both taken up and retained by the renal tubules. Although substantially less GH is retained compared with DMSA, kidney to background activity is comparable for the two agents and they provide renal images of similar quality. ~2-'4 The significant urinary excretion of GH makes possible collecting system visualization, an advantage over DMSA. Both chelates appear superior to 99mTc
rate, separate kidney function and the evaluation of patients who have undergone renal transplantation or have hypertension. These topics have received considerable attention in the literature (including the current volume of this journal) and will not be the subject of this review. Nuclear medicine has less widely appreciated (and less well documented) uses in the evaluation of acute and chronic renal failure. Only a limited and largely anecdotal literature written (not surprisingly) from a radiologic rather than a clinical perspective is available in this area to guide thee nephrologist. This report critically reviews the use of various renal scanning procedures in the adult patient with acute or chronic renal failure in an effort to increase awareness of nuclear medicine's value and perhaps stimulate further studies in this area. ASSESSMENT OF RENAL SIZE
The determination of renal size is of considerable importance to the nephrologist evaluating a patient with renal insufficiency. Normal size suggests recent onset (and potential reversibility) of the renal disease while small kidneys point toward chronicity and irreversibility. Large kidneys suggest specific diagnoses such as amyloidosis or polycystic disease. Radionuclide imaging has been recommended for use in determining kidney size '-3 particularly when plain films are not revealing and intravenous urography is unsuccessful or contraindicated. Because of the delayed transit time of 13'I orthoiodohippurate (OIH) in renal failure,4 Freeman et al. were successful in using this agent to obtain a renal image by rectilinear scanning in 18 of 19 patients with advanced renal failure Seminars in Nuclear Medicine, VoL XII, No. 3 (July), 1982
From the Division of Nephrology, Department of Medicine, University of Medicine and Dentistry--Rutgers Medical School, Piscataway, New Jersey and the Department of Nuclear Medicine, Albert Einstein College of Medicine, Bronx, N. Y. 9 1982 by Grune & Stratton. Inc. 0001-2998/82/1203-0005502.00/0 265
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DTPA for renal imaging in uremia. Studies comparing GH and DMSA with each other in renal failure are not available. GH scanning produces renal visualization in all but "very extreme" renal failure. ~5 Assessment of renal size with DMSA was successful in four of five patients with BUN exceeding 100 mg/dl. Scanning frequently needed to be delayed for 6-10 hr after injection to allow sufficient blood clearance to permit renal imaging. 16 A limiting factor in achieving optimal renal images with 99mTC DMSA in renal failure is DMSA's slow renal uptake compared with the short halffife of 99mTc.97Ru DMSA, a long lived chelate, may eventually offer better renal imaging in patients with advanced renal failure. ~7 Successful renal imaging in uremic patients may be more likely following hemodialysis when radionuclides which are concentrated in the urine are used. 7,s Another factor, particularly for OIH, is increased renal uptake of radionuclides possibly due to removal by dialysis of competing organic anio'as. ~'7"8Renal imaging may be better shortly after an acute reduction in renal function (as with acute tubular necrosis) than later after uremic solutes have accumulated.~'8 Despite considerable success in renal imaging in patients with azotemia, questions remain as to the accuracy of size estimates. When isotopic renal size assessments were compared with surgical nephrectomy specimens Timmermans found
under or over estimates of more than 15% in 4 of 9 patients. Ultrasound estimates of renal size in this study differed from true renal size by more than 15% in only one often cases. ~8 Routine scanning techniques also may underestimate renal size because of angulation of the kidney found in 24 of 62 patients with unilateral diminution of renal size on 99mTc DTPA or DMSA imaging. ~9 Lateral scanning of the kidneys has been recommended when this possibility exists. Renal scanning, while not the procedure of choice, can provide a reasonable estimate of kidney size despite advanced renal failure. The 99mTC chelates, GH and DMSA, and ]31I OIH seem best able to produce good renal images despite minimal kidney function. I23IOIH which has been reported to be superior to '3'I OIH may, when generally available, prove to be the most useful agent in renal failure. 2~ ACUTE RENAL FAILURE Acute Tubular Necrosis
The diagnosis of acute tubular necrosis (ATN) usually is based on the clinical picture, urinalysis and blood and urine chemistries without the necessity for any radiologic or nuclear procedure. Nuclear medicine procedures have, however, been reported to be of value in providing supporting evidence for the diagnosis of ATN, in recognizing disorders mimicking ATN and in providing useful prognostic information.
Table 1. Causes of Renal Failure in Which Nuclear Medicine Studies May Be of Value
Disorder Acute tubular necrosis Hepatorenal syndrome Cortical necrosis Acute pyelonephritis Acute interstitial nephritis Renal artery embolism
Nuclear Medicine Study 1311OIH
99mTcPertechnetate or DTPA 9s~l'c Pertechnetate or DTPA 1311OIH STGallium 99"i'c DMSA or GH 67Gallium 99~-I'c Pertechnetate or DTPA 98"~1"cDMSA, GH or DTPA
Obstructive nephropathy
13~10IH, ~9~i-c DTPA
Chronic pyelonephritis Reflux nephropathy
gg"l'c DMSA, GH 99"~1"cDMSA, GH Radionuclide VCU eTGallium
Renal lymphoma Renal artery stenosis
sg"~l'c Pertechnetate, DTPA
~3;IOIH. s ~ ' c
DTPA, GH, DMSA
Typical Findings Prompt uptake, delayed excretion Markedly diminished RBF Markedly diminished RBF Poor or no visualization Unilateral or bilateral uptake Cortical defects Bilateral intense uptake Unilateral or bilateral absence of RBF Unilateral or bilateral absence of uptake, diffuse or segmental Delayed uptake, prolonged excretion, pelvic accumulation Cortical defects Cortical defects Ureteropelvic reflux Bilateral uptake, often nodular Markedly diminished RRF, often asymmetric Asymmetric renal size
NUCLEAR MEDICINE IN RENAL FAILURE
Only rarely is there difficulty distinguishing ATN from chronic parenchymal renal disease in patients with advanced renal failure. On occasion, however, the prompt uptake of 131I OIH seen in most patients with ATN compared with the poor, delayed uptake found with advanced chronic renal failure is a useful diagnostic point 2'21 (Fig. 1). Schoutens et al. studied ~3~I OIH scanning in 67 patients with severe renal failure, 35 of whom had the clinical picture of ATN. 6 The kidneys of all but 2 of the 35 were adequately visualized. Both of these patients recovered though one was left with moderate renal insufficiency. Among 41 patients with "acute or rapidly progressing" renal failure studied by Staab et al., 14 probably had ATN. s Only one of the 14 had no renal uptake of 131IOIH; this patient subsequently had a "good" recovery. Overall, the absence of renal uptake in 24 patients in the 2 studies was associated in 20 instances with end stage renal disease or death. It was suggested that the assessment of renal uptake of ~mI OIH in patients with severe renal failure helped predict recovery of renal function. 6,s Further review of the data suggest that the assessment of renal OIH uptake did not add to the prognosis based on the clinical diagnosis-patients with acute renal failure did well while those with chronic renal failure or renovascular occlusion did poorly. The poor prognosis of patients with chronic renal failure and nonvisualization on )a~I OIH scanning was confirmed by Sherman and B[aufox who reported that all 16 patients with this finding required chronic dialysis within 6 mo of the scan. 22'23 Caution in the interpretation of the O I H scan in patients with no significant renal function is necessary. Early images may show splenic activity while somewhat later images may demonstrate hepatic activity which can be mistaken for left and right renal uptake respectively. Early uptake i s based largely on organ blood flow; maximum uptake in poorly visualized kidneys would be expected to be a late occurrence22 (Fig. 2). Harwood et al. confined their study of the predictive value of ~31I OIH imaging to patients with a clinical diagnosis of ATN. 7 After 6 mo the 10 patients with a "prominent" renal uptake had a mean creatinine clearance of 80 ml/min while
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the clearance of seven patients with a "faint" uptake was 39 ml/min and that of seven with no renal image apparent was 25 ml/min. Three patients in the no renal image group required chronic hemodialysis while none did so in the prominent renal image group. The prognosis of the three groups could not be determined fully from clinical and laboratory data alone (Fig. 3). Cortical necrosis has been suggested as a likely explanation for the absence of renal OIH uptake in patients with the clinical diagnosis of ATN. 6 This was indeed the finding in 2 of 3 autopsy studies in such patients with this finding on renal scanning. 23The hepatorenal syndrome 6 and renal arterial occlusion 6"s also have been found in patients with acute renal failure and no kidney uptake of ~3~IOIH. Acute renal failure in the patient with a dissecting aneurysm of the aorta may result from renal arterial involvement or from A T N due to renal ischemia or the use of radiocontrast agents. Substantial renal blood flow apparent with 99roTe DTPA or pertechnetate scanning, or prompt uptake of 13tI OIH with delayed excretion suggest ATN and obviates the need for more invasive studies. Renal blood flow in ATN has been shown by Hollenberg et al. (using a 133Xe washout technique) to be reduced to approximately one-third of normal. 24The hepatorenal syndrome, zS"z6cortical necrosis z4"27and renal arterial occlusion z8 may be confused with ATN clinically but differ pathophysiologically in that extreme reduction in renal blood flow is characteristic. This difference in blood flow may be recognized by qualitative radionuclide determination of renal blood flow:9'3~or with a noninvasive 3t-33 or invasive 34'3s quantitative evaluation. The "nuclear filtration fraction" has been advocated by Schlegel and Lang as a diagnostic aid in acute renal failure. 36 The glomerular filtration rate (using 99mTC DTPA or 99roTe iron ascorbate) and renal blood flow (using ~3q OIH) were estimated based on 1-2 min renal uptake of the radionuclides) 7"3s The "nuclear filtration fraction" (glomerular filtration rate divided by renal blood flow) was found to be increased in ATN, decreased in "pre-renal" states and normal with postrenal obstruction. Though using this pseudo-filtration fraction is an intriguing approach felt by these workers to have a "high
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Fig. 1A.
See caption on t h e following page.
sensitivity (95%) for identification of A T N " data adequate to evaluate this claim are not available.
Acute Pyelonephritis Impaired renal function due to acute pyelonephritis is unusual but may be found if the infection is severe, 39 is associated with necrotizing papillitis, or if it complicates underlying chronic renal disease. 4~ Before one can attribute an acute decline in renal function to a urinary tract infection evidence of renal involvement (rather than infection of the bladder alone) must
be present. A typical setting in which this determination may be valuable is in the patient with chronic renal failure and an indwelling bladder catheter who develops fever and an acute decline in renal function. Nuclear medicine studies may help differentiate upper from lower tract infection. Preliminary evidence suggests that renal imaging with 99mTCDMSA or GH may be useful for this problem 41 but 67Gahas been more extensively studied. Hurwitz et al. used 24-hr gallium imaging in 49 patients who had pyelonephritis confirmed or excluded by conventional testing (including 26 examined by invasive methods). 42Among 25 with
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0-3
rain.
131I-Hippuran
6'9
m-rn.
Fig. 1. The typical contrasting pattern of 1311 OIH uptake in ATN and chronic parenchymal renal disease is illustrated. In ATN, uptake is rapid and excretion is delayed or absent. In chronic renal disease, uptake is poor but definite urinary activity is usually present in the bladder. (A} Acute tubular necrosis in a renal transplant. ~ T c - D T P A and 1311OIH studies are shown. Initially, on day 1, perfusion and uptake of the radiolabeled orthoiodohippurate are both somewhat diminished but still present. No significant excretion of the radiolabeled orthoiodohippurate into the bladder is noted. During the subsequent days of study, improvement in perfusion, uptake and excretion of ~31101H are demonstrated, suggesting recovery from acute tubular necrosis. (B) A 42-yr-old hypertensive male patient with history of chronic renal failure (BUN 79 mg/dl, creatinine 5.3 mg/dl). 1311 OIH renal scan demonstrates diminished renal function in both kidneys. Four hour delayed study excludes the evidence of significant postrenal obstruction. Note that both kidneys are smaller than normal and bladder activity is definitely present.
demonstrated upper tract infection 22 had renal uptake of gallium while 4 of 24 with lower tract infection had falsely positive exams. Renal gallium uptake was not normally found at 24 hr by these workers; this contradicted other reports. 43-45 Differences in imaging techniques are the most likely explanation for this discrepancy. Detection of the multiple photopeaks of 67Ga, use of multiple windows with thick septa, middle or high-energy collimator and tomographic capabilities all enhance 67Gaimaging. 46 With current
technology renal images may normally be seen as late as 48 hr after injection. 47 Regardless of technique, renal gallium uptake which increases from the 24 to the 48 hr scan, 43is unilateral, focal or as intense as that of the liver is abnormal. 47 Gallium scanning is a promising, noninvasive method that may aid in the recognition of renal functional deterioration due to pyelonephritis. In addition, the procedure appears useful in localizing renal infection in patients with chronic renal failure due to polycystic kidney disease. ~5Its use
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Fig. 2. (A) Liver and spleen uptake of 13~101H and m"Tc labeled renal agents in advanced renal failure. Posterior scan of the kidney w i t h ~1 OIH (top and b o t t o m left) and of the liver w i t h m"Tc-suIfur colloid (bottom right). Renal scan obtained after the administration of 200 uCi of 13~1OIH and a liver scan after the administration of 2 mCi SS'Tc-Sc. In the 0-3-min exposure (bottom left), a significant accumulation of radioactivity is apparent in the right upper quadrant, corresponding to the area occupied by the liver. Some activity can be noted on the left which approximates the region of the spleen and could easily be mistaken for the left kidney. On the 12-15-min view (top), the activity on the left is essentially cleared but there is still some suggestion of residual activity on the right which could be mistaken for a right kidney. (From Nephron 25:82-86, 1980.) ( B - - P a r t 1 ) A 70-yr-old w o m a n w i t h history of breast carcinoma became azotemic (BUN 70 mg/dl, creatinine 10 mg/dl). The patient complained of bilateral flank pain. To assess renal function and evaluate the possibility of obstructive uropathy, m"Tc-DTPA renal perfusion study and ~311OIH renal scan w e r e performed. Sequential 2-sec images of renal perfusion study demonstrated early m"TC-DTPA activity in the left renal area (arrow) which subsequently was proven to be a spleen. ( B - - P a r t 2) The spleen (arrow) could be easily mistaken for the left kidney. S'~Tc-DTPA activity in the upper quadrant on dynamic and early static phase (1-2-rain bottom left) was liver activity which could be mistaken for the right kidney. One hour delayed S~Tc-DTPA study (top left) reveals somewhat enlarged right kidney. Organ identification is aided by the accompanying sulfur colloid scan (bottom right). ( B - - P a r t 3) ~S~lOIH renal function study (A-C) reveals no left renal activity and very poor right renal function. A, right upper quadrant activity is from liver. B and C, liver activity cleared and delayed right renal uptake seen. One hour delayed m"Tc-DTPA renal scan also demonstrates poor right renal function (D). Within 48 hours, ultrasonographic study of the kidneys confirmed atrophic left kidney and right hydronephrosis with 2-cm renal cortical thickness.
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Scan
Nonvisualization
Ultrasound
Study
No Obstruction
Obstruction
J J J
potential recovery of renal function with surgical relief
Fig. 3.
Bilateral Normal Size
Bilateral
Asymmetric
Small Size
Size
substantial to total impairment of renal function at 6 months
dialysis needed within 6 months
potential reversibility exclude vascular occlusion
Evaluation and prognosis of renal nonvisualization with lall OIH.
is discussed more fully elsewhere in this issue in the article by Handmaker. Acute Interstitial Nephritis Recognition of acute interstitial nephritis (noninfectious) may be easy when the characteristic features are present but more difficult when many of these features are absent and ATN is easily misdiagnosed. 49 Wood et al. first noted the intense, diffuse 48-hr uptake of gallium in three patients with biopsy evidence of this disorder: ~ Linton et al., reporting on nine patients with acute interstitial nephritis due to drugs, described the same finding on gallium scanning. In addition, they studied patients with other renal disorders including six patients with ATN in whom there was no uptake of the isotope. They suggested that gallium scanning may help distinguish patients with acute interstitial nephritis from those with ATN.49 Renal gallium uptake is not uniformly absent in ATN. George et al. described 12 patients with renal transplants and ATN whose kidneys accumulated the isotope# l Kumar and Coleman reported three patients with ATN two of whom
were renal transplant patients) 2 The extent and intensity of the renal uptake was not described in either report. Though ATN is frequently listed as a cause of renal gallium uptake 15'44other reports of this observation in patients other than recipients of a renal transplant are scarce. 43 Impaired renal function has also been suggested as a cause of delayed (beyond 24 hr) renal visualization with gallium 43 but evidence to support this contention is lacking. The evidence to date suggests that gallium scanning is a useful means of differentiating acute interstitial nephritis from ATN, particularly when urinary tract infection is absent and renal uptake is diffuse and intense (Fig. 4). Renal Artery Embolism Renal artery embolism should be considered as a cause of acute renal failure particularly in patients with atrial fibrillation or acute myocardial infarction. Radionuclide studies can play a major diagnostic role in this disorder. Early reports on patients with renal artery embolism noted the good correlation of 99rnTc pertechnetate flow studies with renal arteriogra-
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]
..............
.....
Fig. 4. (A) A 45-yr-old female patient presented with an acutely rising BUN (71 mg/dl) and creatinine (5.5 mg/dl), Clinical diagnosis was strongly suspicious for acute interstitial nephritis. Slightly delayed lSll OIH concentration and markedly delayed excretion is noted in both kidneys. Twenty-four hour renal scan demonstrates significant tracer excretion from the kidneys making obstruction unlikely. Each view illustrates 3-min sclntiphoto. Renal ultrasonogram showed normal renal size without obstruction. (B) Posterior view of STGallium-citrate renal scan at 48 hr. reveals substantial radiogallium concentration in both kidneys.
phy. 29'53Lessman et al. reported on 17 cases with renal artery embolism 15 of whom had acute renal failure.54 99mTc pertechnetate perfusion scanning showed unilateral or bilateral absence of renal blood flow in nine of ten cases studied and the remaining patient had bilateral perfusion defects. In the eight patients who also underwent angiography the findings were virtually identical. Even when renal artery embolism does not completely interrupt renal blood flow, renal failure may occur in association with multiple parenchymal infarcts. 13zI OIH was diagnostic in this situation in a patient with endocarditis and renal failure.6 More recently 99mTC DTPA, 55 99mTCGH 15and 99mTcDMSA 12'13have been used and advocated for recognition of this problem. When the diagnosis of acute renal failure due to renal artery embolism is under consideration, renal scanning may be of considerable value in
recognizing as well as excluding the diagnosis.6"53 Arteriography may not be necessary unless there are plans for surgical intervention3'54'56 (Fig. 5). OBSTRUCTIVE NEPHROPATHY
Isotopic scanning techniques appear suitable for demonstrating urinary tract obstruction in patients with relatively normal renal function,s7 Since visualization of the collecting system depends on glomerular filtration and/or tubular secretion renal insufficiency must, to a varying extent, impair the sensitivity of kidney scanning for recognition of hydronephrosis. Despite this basic difficulty scanning may be useful in patients with renal insufficiency and urinary tract obstruction and has been advocated for diagnostic use in this setting} '57 When routine studies are inconclusive in the patient with possible obstructive nephropathy delayed imaging will often produce useful mor-
NUCLEAR MEDICINE IN RENAL FAILURE
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Fig. 5. (A) A 74-yr-old man was admitted to the hospital with a pulsatile abdominal mass. The patient had history of right nephrectomy for renal calculi performed 24 yr ago. Retrograde femoral aortogram reveals large aneurysm of lower abdominal aorta. Solitary left renal artery is visible (arrow). (B) Scintiphotographic studies w e r e performed for oliguria which developed after placement of an aorto-iliac by-pass graft. A, posterior lSTHg chlormerodrin study fails to reveal any renal activity. S-D, m"Tc-pertechnetate study fails to show any kidney perfusion. Aortic surgical site is seen as defect in isotope column (arrow). E-F, 131101H study fails to reveal renal concentration, suggesting renal artery occlusion rather than ATN or dehydration, other diagnosis which were considered. (C) Repeat aortogram shows occlusion of solitary left renal artery (arrow). Surgical clips from by-pass graft aortic operation are apparent. An embolic atheromatous plaque was removed at surgery. (From J Urol 105:473-481, 1971.)
phological information. 2'6'57 When substantial renal insufficiency is present and imaging beyond 24 hr is contemplated, 1311OIH may be superior to 99mTC chelates 57 due to its longer halflife. Malave et al. studied 56 patients with suspected hydronephrosis, half with renal failure, using 131IOIH and 99mTc DTPA. 5s Images were not obtained beyond one hour for DTPA or 30 min for OIH. In 1 I% a false positive diagnosis of hydronephrosis was made while in 26% the results were inconclusive as a result of poor renal uptake of the isotopes. Scanning was felt to be accurate only with normal or moderately
impaired renal function but was useful regardless of the degree of renal impairment in following interval changes in the function of the obstructed kidney. Absence of renal uptake of 131IOIH in patients with obstructive nephropathy does not preclude substantial recovery of kidney function. This applies to both unilateral 59'6~ and bilateral obstructive disease. 61 The use of ultrasound to detect urinary tract obstruction has increased dramatically in recent years. While highly sensitive in the detection of hydronephrosis a substantial false positive rate (26%) has been reported. 62 With improving
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equipment and diagnostic criteria better specificity has been noted58'63 but the further evaluation of patients with dilated collecting systems may present problems if, as with chronic renal failure, 64 avoidance of intravenous contrast media is desirable. Diuretic radionuclide renography may help differentiate a dilated obstructed collecting system from one which is dilated but has no mechanical obstruction.65~8 Renal retention of the administered radionuclide occurs with hydronephrosis regardless of the presence or absence of mechanical obstruction due to dilution of the isotope in the large collecting system volume with a lower isotopic concentration per unit volume of urine passed into the bladder. The unobstructed hydronephrotic kidney should respond to diuretics with an increased urine volume and radioisotope clearance; the mechanically obstructed kidney is unlikely to respond. 66 This methodology is discussed in detail in the article on obstructive uropathy in this issue. In patients with renal failure66this method can be applied successfully if the collecting system is adequately visualized and a diuresis achieved. Measurement of urine volume following the diuretic injection may be helpful69 as may increasing the dose of furosemide. While an obstructive pattern may reflect poor renal function, a dilated, nonobstructive pattern will still effectively rule out mechanical urinary tract
obstruction .66 CHRONIC RENAL FAILURE Chronic Pyelonephritis
Recognition of chronic nonobstructive pyelonephritis in the adult may be difficult since a positive urine culture and pyuria are nonspecific and the "classical" changes on urography (calyceal blunting and deformity with depression of the overlying cortex) are seen most commonly in childhood as a result of vesicoureteral reflux, v~ Adults with pyelonephritis may have advanced histologic damage without apparent abnormality on urography.7! Davies et al. used 19VHg chloromerodrin to study 50 patients with the clinical diagnosis of chronic pyelonephritis and normal urography.72 Despite the poor image resolution that was possible with the agent and equipment used, localized renal defects were seen in 10 patients.
McAfee reported on 31 patients with chronic pyelonephritis (seven with renal insufficiency) who underwent urography and renal scans with 99mTc GH and 131I OIH and had abnormalities in one of these studies. 73Although the overall sensitivity to renal morphologic abnormalities was greater with urography than with scanning, focal parenchymal damage was better seen with nuclear imaging in eight patients and GH was more useful than OIH. As might be expected 99mTc DMSA also has been reported to facilitate assessment of cortical scarring in pyelonephri-
tis.9,15,16 Unlike urography, renal scans can demonstrate intraparenchymal abnormalities which do not deform the collecting system or renal outline. Nuclear imaging may therefore be a useful supplement to urography for detection of renal damage due to chronic pyelonephritis. Active renal infection may, however, result in scanning defects which resolve with timefl '72 Chronic pyelonephritis (as well as renovascular disease and unilateral obstruction) may result in asymmetric renal damage unlike glomerular disease or nephrosclerosis which tend to cause symmetrical dysfunction. Recognition of differences in radioisotope uptake may, to a minor extent, aid in recognition of these disorders. 74 Reflux Nephropathy
Reflux nephropathy, recognized as an importent renal disorder in children, has been increasingly recognized in adults as a cause of hypertension, proteinuria, and renal failure that may progress to end-stage renal disease. 75'v6 The direct radionuclide voiding cystourethrogram (VCU) (using suprapubic puncture or bladder catheterization) is useful for the detection and follow-up of patients with clinically significant vesicoureteric reflux, vv'v8 Though it is often used in children to minimize radiation exposure it may be used in adults. The intravenous radionuclide VCU is an attractive noninvasive method for detecting reflux v9 but, because of the prolonged excretion of the isotope, is not recommended for use in patients with renal insufficiency, s~ Recognition of reflux despite renal failure may be possible using the computer analysis described for diuretic radionuclide renography.66
Fig. 6. (A) A 30-yr-old female with hypertension. Physical examination revealed bruit in right flank. IVP was normal and digital radiographic study of the kidneys appeared normal, m"Tc-GH and 13~1OIH renal scan w e r e done because of persistent hypertension which was refractory to therapy. An early dynamic renal study (m"Tc-GH 6 - 8 sec.) demonstrates asymmetry of renal perfusion w i t h diminished right renal blood f l o w and 2 hr static image shows reduced right renal size with some segmental loss of cortex while left kidney shows normal size and contour.
Angiographic study reveals normal left renal artery but right renal artery demonstrates flbromusuclar dysplasia (arrow). (B) Transluminal angioplasty was done. Note preoperative lS~l OIH renal scan with delayed right renal tracer concentration and excretion. Cross-over sign compatible w i t h renovascular disease is seen on renogram curves between right and left kidney prior to angioplasty. Postoperative seventh day :Sll OIH renal scan shows improvement of right renal function.
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Renal Lymphoma Renal insufficiency is a common complication of malignant lymphomas and results from hypercalcemia, uric acid nephropathy, glomerulopathies, dehydration, urinary tract obstruction, amyloidosis, or, in 12%-14% of patients, 81 lymphomatous infiltration of the kidneys. Gallium scanning will detect lymphomatous organ involvement, including that of the kidney, 82 with a sensitivity of from 30 to more than 75% depending upon the imaging equipment used and, possibly, the histologic class of the lymphoma.83 Gallium scanning may be of value in evaluating the patient with lymphoma and renal failure. A multinodular pattern of renal involvement, detectable on scanning, 84 is 10 times more common at autopsy than diffuse involvement,8~ making the pattern of gallium uptake useful. Urography and ultrasound may be unable to differentiate renal cysts from lymphomatous nodules. 84 More studies of gallium scanning in renal lymphoma are needed before the actual value of the exam can be assessed. Renal Artery Stenosis Renal artery stenosis, in addition to its role in hypertension, is an important, potentially treatable cause of renal failure. It has become increasingly recognized that even prolonged vascular occlusion does not preclude successful repair of the stenosis with recovery of renal function, ss As with renal artery embolism, radioisotope scanning with 99mTCpertechnetate or DTPA has been used to assess renovascular patency with a high degree of accuracy. 2s,86 The absence of perfusion on flow studies is not diagnostic of complete vascular occlusion but the additional observation of no uptake of OIH indicates an essentially nonperfused kidney, g7 More sophisticated techniques that allow noninvasive, quanti-
tative assessment of renal blood flow 31-33 also may be of value in this setting. Percutaneous transluminal angioplasty is currently felt to be indicated for renal failure due to renal artery stenosis s8 and has been successfully used in patients with this disorder. 89'9~Radionuclide studies may be of benefit in evaluating the success of "balloon" angioplasty as well in recognizing complications from the procedures (Fig. 6). Born et al. 91 used 99mTCpertechnetate, 131I OIH and 99mTCDTPA to demonstrate improved renal function in three patients following angioplasty. Kuhlmann et al. studied eight patients with renal artery stenosis, hypertension and, in half the cases, renal insufficiency who were treated with percutaneous transluminal angioplasty. 92 All those with impaired kidney function improved with restoration of renal blood flow. Measurement of renal plasma flow using 13tI OIH clearances with determination of individual kidney components utilizing a computer-linked gamma camera were undertaken prior to and every 2 mo during the 6-month follow-up period. Both vascular complications of the angioplasty (occlusion of a renal artery and the development of a slight renal artery restenosis) were suspected on the basis of the isotope studies and confirmed angiographically. Serial isotopic measurements of renal plasma flow were felt to provide a good, noninvasive method for evaluating the effects of the vascular procedure. A thorough understanding of the wide variety of conditions in which radionuclide imaging can be achieved is essential to its use. In the patient presenting with renal failure, a planned logical approach may prove of considerable value to the clinician in the differential diagnosis and prognosis of the patients' illness. ACKNOWLEDGMENT
The excellentsecretarial assistance of Donna MacGregor is gratefullyacknowledged.
REFERENCES
1. Reba RC, Poulose KP, Kirchner PT: Radiolabeled chelates for visualization of kidney function and structure with emphasison their use in renal insufficiency.SeminNucl Med 4:151-168, 1974 2. JacobsRP, Laing FC, KorobkinM, et al: Renal failure, in RosenfieldAT, GlickmanMG, HodsonJ (eds): Diagnostic Imaging in Renal Disease. New York, Appleton-CenturyCrofts, 1979,pp 299-325
3. Atkins HL, Freeman LM: The investigation of renal disease using radionuclides. Postgrad Med J 49:503-516, 1973 4. BlaufoxMD, Conroy M: Measurement of renal mean transit time of hippuran ~3~Iwith external counting. J Nucl Biol Med 12:107-116, 1968 5. Freeman LM, Goldman SM, Shaw RK, et al: Kidney
NUCLEAR MEDICINE IN RENAL FAILURE
visualization with ~3q-ortho-iodohippurate in patients with renal insufficiency. J Nucl Med 10:545-549, 1969 6. Schoutens A, Dupuis F, Toussaint C: ~3q-Hippuran scanning in severe renal failure. Nephron 9:275-290, 1972 7. Harwood TH, Hiesterman DR, Robinson RG, et al: Prognosis for recovery of function in acute renal failure. Arch Intern Med 136:916-919, 1976 8. Staab EV, Hopkins J, Patton DD, et al: The use of radionuclide studies in the prediction of function in renal failure. Radiology 106:141-146, 1973 9. O'Reilly PH, Shields RA, Testa H J: Renovascular hypertension and renal failure, in O'Reilly PH, Shields RA, Testa HJ (eds): Nuclear Medicine in Urology and Nephrology. London, Butterworths, 1979, pp 81-85 10. Chervu LR, Freeman LM, Blaufox MD: Radiopharmaceuticals for renal studies. Semin Nucl Med 4:3-22, 1974 11. Jakubowski W, Graban W, Licinska I, et al: Comparative investigations of renal scanning agents. Eur J Nucl Med 3:33-39, 1978 12. Kirchner PT, Berman H: Radioisotopic imaging, in Rosenfield AT, Glickman MG, Hodson J (eds): Diagnostic Imaging in Renal Disease. New York, Appleton-CenturyCrofts, 1979, pp 63-72 13. Arnold RW, Subramanian G, McAfee JG, et al: Comparison of 99'~Tc complexes for renal imaging. J Nucl Med 16:357-367, 1975 14. O'Reilly PH, Shields RA, Testa H J: Radiopharmaceuticals, in O'Reilly PH, Shields RA, Tests HJ (eds): Nuclear Medicine in Urology and Nephrology. London, Butterworths, 1979, pp 148-152 15. Kahn PC: Renal imaging with radionuclides, ultrasound, and computed tomography. Semin Nucl Med 9:4357, 1979 16. Handmaker H, Young BW, Lowenstein JM: Clinical experience with 99"Tc-DMSA (dimercaptosuccinic acid), a new renal-imaging agent. J Nucl Med 16:28-32, 1975 17. Oster ZH, Som P, Gil MC, et al: 97Ru-DMSA for delayed renal imaging. Radiology 141 : 185-190, 1981 18. Timmermans L: A comparison of radioisotopic and ultrasonic scanning of the kidney, in zum Winkel K, Blaufox MD, Funck-Brentano JL (eds): Radionuclides in Nephrology. Stuttgart, Thieme, 1975, pp 101-106 19. Kohn HD, Mostbeck A: Value of additional lateral scans in renal scintigraphy. Eur J Nucl Med 4:21-25, 1979 20. Herman H J, Lange D, Eisenhut M, et al: Radiation dose and labeling of hippuran, in Bianchi C, Blaufox MD (eds): Unilateral Renal Function Studies. Basel, Karger, 1978, pp 100-104 21. Hattner RS, Maltz HE, Holliday MA: Differentiation of reversible ischemia from end-stage renal failure in nephrotic children with ~3q-hippurate dynamic scintigraphy. J Nucl Med 18:438-440, 1977 22. Sherman RA, Blaufox MD: Clinical significance of nonvisualization with 13tI-Hippuran renal scan, in Hollenberg NK, Lange S (eds): Radionuclides in Nephrology. Stuttgart, Thieme, 1980, pp 235-239 23. Sherman RA, Blaufox MD: Obstructive uropathy in patients with non-visualization on renal scan. Nephron 25:82-86, 1980 24. Hollenberg NK, Epstein M, Rosen SM, r al: Acute oliguric renal failure in man: evidence for preferential renal cortical ischemia. Medicine 17:455-474, 1968
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25. Epstein M, Berk DP, Hollenberg NK: Renal failure in the patient with cirrhosis. Am J Med 49:175-185, 1970 26. Hollenberg NK, Mangel R, Fung HYM: Assessment of intrarenal perfusion with radioxenon: A critical review of analytical factors and their implications in man. Semin Nucl Med 6:193-215, 1976 27. Kleinknecht D, Grunfeld JP, Gomez PC, et al: Diagnostic procedures and long-term prognosis in bilateral renal cortical necrosis. Kidney lnt 4:390--400, 1973 28. Bell EG, McAfee JG, Makhuli ZN: Medical imaging of renal diseases--Suggested indications for different modalities. Semin Nucl Med 11:105-127, 1981 29. Freeman LM, Meng CH, Richter MW, et al: Patency of major renal vascular pathways demonstrated by rapid blood flow scintiphotography. J Urol 105:473-481, 1971 30. Hennessy WT, Pollack HM, Banner MP, et al: Radiologic evaluation of anuric patient. Urology 18:435-445, 1981 31. Smart R, Trew P, Burke 3, et al: Simplified estimation of glomerular filtration rate and effective renal plasma flow. Eur J Nucl Med 6:249-253, 1981 32. van Herk G, de Zeeuw D: Unilateral kidney blood flow measurement using the S~Rb/8~mKrratio, in Bianchi C, Blaufox MD (eds): Unilateral renal function studies. Basel, Karger, 1978, pp 67-72 33. Constable AR, Hussein MM, Albrecht MP, et al. Renal clearance determined from single plasma samples, in Hollenberg NK, Lange S (eds): Radionuclides in Nephrology. Stuttgart, Thieme, 1980, pp 62~i6 34. Grunfeld JP, Sabto J, Bankir L, et al: Methods for measurement of renal blood flow in man. Semin Nucl Med 4:39-50, 1974 35. Heidenreich P, Oberdorfer M, Hor G, et al: Estimation of renal blood flow by means of technetium-99m and xenon-133, in zum Winkel K, Blaufox MD, Funck-Brentano JL (eds): Radionuclides in Nephrology. Stuttgart, Thieme, 1974, pp 58-66 36. Schlegel JU, Lang EK: Computed radionuclide urogram for assessing acute renal failure. Am J Roentgenol 134:1029-1934, 1980 37. Schlegel JU, Hamway SA: Individual renal plasma flow determination in 2 minutes. J Urol 116:282-285, 1976 38. Schlegel JU, Halikiopoulos HL, Prima R: Determination of filtration fraction using the gamma scintillation camera. J Urol 122:447-450, 1979 39. Cotran RS, Pennington JE: Urinary tract infection, pyelonephritis, and reflux nephropathy, in Brenner BM, Rector FC (eds): The Kidney. Philadelphia, Saunders, 1981, pp 1571-1632 40. Freedman LR: Interstitial renal inflammation, including pyelonephritis and urinary tract infection, in Earley LE, Gottschalk CW (eds): Strauss and Welt's Diseases of the Kidney. Boston, Little, Brown, 1979, pp 817-876 41. Handmaker H, Young B, Fay R: Nuclear renal imaging in acute pyelonephritis. J Nucl Med 20:623, 1979 42. Hurwitz SR, Kessler WO, Alazraki NP, et al: Gallium-67 imaging to localize urinary-tract infections. Br J RadioI. 49:156-I 60, 1976 43. Staab EV, McCartney WH: Role of gallium-67 in inflammatory disease. Semin Nucl Med 8:219-234, 1978 44. Henkin RE: Gallium-67 in the diagnosis of inflamma-
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tory disease, in Hoffer PB, Bekerman C, Henkin RE (eds): Gallium-67 Imaging. New York, Wiley, 1978, pp 65-92 45. Larson SM, Hoffer PB: Normal patterns of localization, in Hoffer PB, Bekerman C, Henkin RE (eds): Gallium67 Imaging. New York, Wiley, 1978, pp 23-38 46. Hoffer PB: Imaging technique, in Hoffer PB, Bekerman C, Henkin RE (eds): Gallium-67 Imaging. New York, WiIey, I978, pp 9-2I 47. Hauser MF, Alderson PO: Gallium-67 imaging in abdominal disease. Semin Nucl Med 8:251-270, 1978 48. Mendex G, Morillo G, Alonso M, et al: Gallium-67 radionuclide imaging in acute pyelonephritis. Am J Roentgenol 134:17-22, 1980 49. Linton AL, Clark WF, Driedger AA, et al: Acute interstitial nephritis due to drugs. Ann Intern Med 93:735741, 1980 50. Wood BC, Sharma JN, Germann DR, et al: Gallium citrate Ga 67 imaging in noninfectious interstitial nephritis. Arch Intern Med 138:1665-1666, 1978 51. George EA, Codd JE, Newton WT, et al: 67Ga citrate in renal allograft rejection. Radiology 117:731-733, 1975 52. Kumar B, Coleman RE: Significance of delayed 67Ga localization in the kidneys. J Nucl Med 17:872-875, 1976 53. Hartenbower DL, Winston MA, Weiss ER, et al: The scintillation camera in embolic acute renal failure. J Urol 104:799-802, 1970 54. Lessman RK, Johnson SF, Coburn JW, et al: Renal artery embolism. Ann Intern Med 89:477~,82, 1978 55. Sanders RC, Menon S, Sanders AD: The complementary uses of nuclear medicine and ultrasound in the kidney. J Urol 120:521-527, 1978 56. Freeman LM: Rapid blood flow scintiphotographic studies of renal trauma and infarction, in Blaufox MD, Funck-Brentano JL (eds): Radionuclides in Nephrology. New York, Grune & Stratton, 1972, pp 281-287 57. Kirchner PT, James AE, Reba RC, et al: Patterns of excretion of radioactive chelates in obstructive uropathy. Radiology 114:655~161, 1975 58. Malave SR, Neiman HL, Spies SM, et al: Diagnosis of hydronephrosis: Comparison of radionuclide scanning and sonography. Am J Roentgenot 135:1179-1185, 1980 59. KatuI M J, Wax SH: Evaluation of renal function during experimental hydronepbrosis by means of the radioisotope renogram. Surg Gynecol Obstet 126:563-571, 1968 60. Joekes AM: Obstructive uropathy. Semin Nucl Med 4:187-196, 1974 61. Sherman RA, Blaufox MD: Obstructive uropathy in patients with nonvisualization on renal scan. Nephron 25:8286, 1980 62. Ellenbogen PH, Scheible FW, Talner LB, et al: Sensitivity of gray scale ultrasound in detecting urinary tract obstruction. Am J Roentgenol 130:731-733, 1978 63. Talner LB, Scheible W, Ellenbogen PH, et al: How accurate is ultrasonography in detecting hydronephrosis in azotemic patients ? Urol Radiol 3:1-6, 1981 64. Byrd L, Sherman RL: Radiocontrast-induced acute renal failure: A clinical and pathophysiologic review. Medicine 58:270-279, 1979 65. O'Reilly PH, Lupton EW, Testa H J, et al: The diuresis renogram, in Hollenberg NK, Lange S (eds): Radionuclides in Nephrology. Stuttgart, Thieme, 1980, pp 216220
SHERMAN AND BYUN
66. Thrall JH, Koff SA, Keyes JW: Diuretic radionuclide renography and scintigraphy in the differential diagnosis of hydroureteronephrosis. Semin Nucl Med 11:89-104, 1981 67. O'Reilly PH, Testa H J, Lawson RS, et al: Diuresis renography in equivocal urinary tract obstruction. Br J Urol 50:76--80, 1978 68. KoffSA, Thrall JH, Keyes JW: Diuretic radionuclide urography: A non-invasive method for evaluating nephroureteral dilatation. J Urol 122:451~154, 1979 69. Koff SA, Thrall JH, Keyes JW: Assessment of hydroureteronephrosis in children using diuretic radionuelide urography. J Urol 123:531-534, 1980 70. Hodson C J: The radiological contribution toward the diagnosis of chronic pyelonephritis. Radiology 88:857-871, 1967 71. Saunders CD, Corriere JN: The inability to diagnose chronic pyelonephritis on the excretory urogram in adults. J Urol 111:560--562, 1974 72. Davies ER, Roberts M, Roylance J, et al: The renal scintigram in pyelonephritis. Clin Radiol 23:370-376, 1972 73. McAfee JG: Radionuclide imaging in the assessment of primary chronic pyelonephritis~ Radiology 133:203-206, 1979 74. Meldolesi U, Casucci R, Comotti L: An analysis of the diagnostic contribution of double-radiocompound renography. Eur J Nucl Med 2:63-66, 1977 75. Kincaid-Smith P, Becket G J: Reflux nephropathy in the adult, in Hodson J, Kincaid-Smith P (eds): Reflux Nephropathy. New York, Masson, 1979, pp 21-28 76. Bailey RR: End-stage reflux nephropathy. Nephron 27:302-306, 1981 77. Blaufox MD, Gurskin A, Sandier P, et al: Radionuclide scintigraphy for detection of vesicoureteral reflux in children. J Pediatr 79:239-246, 1971 78. Conway J J, King LR, Belman AB, et al: Detection of vesicoureteral reflux with radionuclide cystography. Am J Roentgenol 115:720-727, 1972 79. Hedman JK, Kempi V, Voss H: Measurement of vesicoureteral reflux with intravenous 99mTc-DTPA compared to radiographic cystography. Radiology 126:205-208, 1978 80. Conway J J, Betman AB, King LR, et at: Direct and indirect radionuclide cyslography. J Urol 113:689--693, 1975 81. Richmond J, Sherman RS, Diamond HD, et al: Renal lesions associated with malignant lymphomas. Am J Med 32:184-206, 1962 82. Frankel RS, Riehman SD, Levenson SM, et al: Renal localization of gallium-67 citrate. Radiology 114:393-397, 1975 83. Turner DA, Fordham EW, Ali A, et al: Gallium-67 imaging in the management of Hodgkin's disease and other malignant lymphomas. Semin Nucl Med 8:205-218, 1978 84. Shirkhoda A, Staab EV, Mittelstaedt CA: Renal lymphoma imaged by ultrasound and gallium-67. Radiology 137:175-180, 1980 85. Gulbrandson RN, Al-Bermani J, Gaspard D J: Successful renal revascularization after prolonged nonfunction. JAMA 238:2522-2523, 1977 86. Benedetti-Valentini F, Massa R, Fiorani P, et al: Sequential scintigraphy in diagnosis and postoperative studies of renovascular hypertension, in Bianchi C, Blaufox MD
NUCLEAR MEDICINE IN RENAL FAILURE
(eds): Unilateral Renal Function Studies. Basel, Karger, 1978, pp 89-91 87. Koenigsberg M, Freeman LM, Blaufox MD: Radionuclide and ultrasound evaluation of renal morphology and function, in Edelman CM (ed): Pediatric Kidney Disease. Boston, Little, Brown, 1978, pp 236-261 88. Slater EE: Percutaneous transluminal angioplasty of the renal artery: A hypertensiologist's view. Cardiovasc Intervent Radiol 3:205-206, 1980 89. Logan AG, Steinhardt MI: Restoration of renal func-
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tion by unilateral percutaneous transluminal dilatation of stenosed renal artery. Can Med Assoc J 122:910-912, 1980 90. Schwarten DE: Percutaneous transluminal angioplasty of the renal artery. Cardiovasc Intervent Radiol 3:197-206, 1980 91. Born ML, Gerlock A J, Goncharenko V, et al: Radionuclide evaluation of renal artery dilatation. Cardiovasc Intervent Radiol 4:177-182, 1981 92. Kuhlmann U, Vetter W, Furrer J, et al: Renovascular hypertension: treatment by percutaneous transluminal dilatation. Ann Intern Med 92:1-6, 1980
in t h e diagnosis and management of t h e patient w i t h obstructive or reflux nephropathy may be obtained. Radionuclide studies in patients w i t h chronic renal failure m a y help make apparent such causes as renal artery stenosis, chronic pyelonephritis or lymphomatous kidney infiltration. Future correlation of scanning results w i t h renal pathology promises to further expand nuclear m e d i c i n e ' s utility in t h e noninvasive diagnosis of renal disease.
ENERALLY recognized uses for nuclear G medicine in nephrology include the assessment of renal blood flow, glomerular filtration
(mean BUN 96 mg/dl, creatinine 7.6 mg/dl) and inadequate visualization with ~97Hg chloromerodrin, s While renal size was often inexplicably large despite chronic parenchymal disease, there was confirmation of this finding by high dose urography. Other reports confirm the value of 131l OIH in demonstrating renal size despite severe renal impairment.6-8 Renal concentration of OIH occurs with as little as 3% of normal function? Because of the excellent imaging characteristics of 99mTC,its various chelates are quite useful in renal failure. '~ This accounts for the superiority of 99mTCdiethylenetriamine pentaacetic acid (DTPA) over 197Hg chloromerodrin in imaging the failing kidney~ despite excretion of the former wholely by glomerular filtration and the progressive renal uptake with minimal excretion of the latter, lz-~4 Reba estimated that renal size could be determined with 99mTCDTPA in 75% of patients with BUN over 65 mg/dl.' In addition to the advantages of carrying the 99mTCmoiety, glucoheptonate (GH) and dimercaptosuccinic acid (DMSA) are both taken up and retained by the renal tubules. Although substantially less GH is retained compared with DMSA, kidney to background activity is comparable for the two agents and they provide renal images of similar quality. ~2-'4 The significant urinary excretion of GH makes possible collecting system visualization, an advantage over DMSA. Both chelates appear superior to 99mTc
rate, separate kidney function and the evaluation of patients who have undergone renal transplantation or have hypertension. These topics have received considerable attention in the literature (including the current volume of this journal) and will not be the subject of this review. Nuclear medicine has less widely appreciated (and less well documented) uses in the evaluation of acute and chronic renal failure. Only a limited and largely anecdotal literature written (not surprisingly) from a radiologic rather than a clinical perspective is available in this area to guide thee nephrologist. This report critically reviews the use of various renal scanning procedures in the adult patient with acute or chronic renal failure in an effort to increase awareness of nuclear medicine's value and perhaps stimulate further studies in this area. ASSESSMENT OF RENAL SIZE
The determination of renal size is of considerable importance to the nephrologist evaluating a patient with renal insufficiency. Normal size suggests recent onset (and potential reversibility) of the renal disease while small kidneys point toward chronicity and irreversibility. Large kidneys suggest specific diagnoses such as amyloidosis or polycystic disease. Radionuclide imaging has been recommended for use in determining kidney size '-3 particularly when plain films are not revealing and intravenous urography is unsuccessful or contraindicated. Because of the delayed transit time of 13'I orthoiodohippurate (OIH) in renal failure,4 Freeman et al. were successful in using this agent to obtain a renal image by rectilinear scanning in 18 of 19 patients with advanced renal failure Seminars in Nuclear Medicine, VoL XII, No. 3 (July), 1982
From the Division of Nephrology, Department of Medicine, University of Medicine and Dentistry--Rutgers Medical School, Piscataway, New Jersey and the Department of Nuclear Medicine, Albert Einstein College of Medicine, Bronx, N. Y. 9 1982 by Grune & Stratton. Inc. 0001-2998/82/1203-0005502.00/0 265
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DTPA for renal imaging in uremia. Studies comparing GH and DMSA with each other in renal failure are not available. GH scanning produces renal visualization in all but "very extreme" renal failure. ~5 Assessment of renal size with DMSA was successful in four of five patients with BUN exceeding 100 mg/dl. Scanning frequently needed to be delayed for 6-10 hr after injection to allow sufficient blood clearance to permit renal imaging. 16 A limiting factor in achieving optimal renal images with 99mTC DMSA in renal failure is DMSA's slow renal uptake compared with the short halffife of 99mTc.97Ru DMSA, a long lived chelate, may eventually offer better renal imaging in patients with advanced renal failure. ~7 Successful renal imaging in uremic patients may be more likely following hemodialysis when radionuclides which are concentrated in the urine are used. 7,s Another factor, particularly for OIH, is increased renal uptake of radionuclides possibly due to removal by dialysis of competing organic anio'as. ~'7"8Renal imaging may be better shortly after an acute reduction in renal function (as with acute tubular necrosis) than later after uremic solutes have accumulated.~'8 Despite considerable success in renal imaging in patients with azotemia, questions remain as to the accuracy of size estimates. When isotopic renal size assessments were compared with surgical nephrectomy specimens Timmermans found
under or over estimates of more than 15% in 4 of 9 patients. Ultrasound estimates of renal size in this study differed from true renal size by more than 15% in only one often cases. ~8 Routine scanning techniques also may underestimate renal size because of angulation of the kidney found in 24 of 62 patients with unilateral diminution of renal size on 99mTc DTPA or DMSA imaging. ~9 Lateral scanning of the kidneys has been recommended when this possibility exists. Renal scanning, while not the procedure of choice, can provide a reasonable estimate of kidney size despite advanced renal failure. The 99mTC chelates, GH and DMSA, and ]31I OIH seem best able to produce good renal images despite minimal kidney function. I23IOIH which has been reported to be superior to '3'I OIH may, when generally available, prove to be the most useful agent in renal failure. 2~ ACUTE RENAL FAILURE Acute Tubular Necrosis
The diagnosis of acute tubular necrosis (ATN) usually is based on the clinical picture, urinalysis and blood and urine chemistries without the necessity for any radiologic or nuclear procedure. Nuclear medicine procedures have, however, been reported to be of value in providing supporting evidence for the diagnosis of ATN, in recognizing disorders mimicking ATN and in providing useful prognostic information.
Table 1. Causes of Renal Failure in Which Nuclear Medicine Studies May Be of Value
Disorder Acute tubular necrosis Hepatorenal syndrome Cortical necrosis Acute pyelonephritis Acute interstitial nephritis Renal artery embolism
Nuclear Medicine Study 1311OIH
99mTcPertechnetate or DTPA 9s~l'c Pertechnetate or DTPA 1311OIH STGallium 99"i'c DMSA or GH 67Gallium 99~-I'c Pertechnetate or DTPA 98"~1"cDMSA, GH or DTPA
Obstructive nephropathy
13~10IH, ~9~i-c DTPA
Chronic pyelonephritis Reflux nephropathy
gg"l'c DMSA, GH 99"~1"cDMSA, GH Radionuclide VCU eTGallium
Renal lymphoma Renal artery stenosis
sg"~l'c Pertechnetate, DTPA
~3;IOIH. s ~ ' c
DTPA, GH, DMSA
Typical Findings Prompt uptake, delayed excretion Markedly diminished RBF Markedly diminished RBF Poor or no visualization Unilateral or bilateral uptake Cortical defects Bilateral intense uptake Unilateral or bilateral absence of RBF Unilateral or bilateral absence of uptake, diffuse or segmental Delayed uptake, prolonged excretion, pelvic accumulation Cortical defects Cortical defects Ureteropelvic reflux Bilateral uptake, often nodular Markedly diminished RRF, often asymmetric Asymmetric renal size
NUCLEAR MEDICINE IN RENAL FAILURE
Only rarely is there difficulty distinguishing ATN from chronic parenchymal renal disease in patients with advanced renal failure. On occasion, however, the prompt uptake of 131I OIH seen in most patients with ATN compared with the poor, delayed uptake found with advanced chronic renal failure is a useful diagnostic point 2'21 (Fig. 1). Schoutens et al. studied ~3~I OIH scanning in 67 patients with severe renal failure, 35 of whom had the clinical picture of ATN. 6 The kidneys of all but 2 of the 35 were adequately visualized. Both of these patients recovered though one was left with moderate renal insufficiency. Among 41 patients with "acute or rapidly progressing" renal failure studied by Staab et al., 14 probably had ATN. s Only one of the 14 had no renal uptake of 131IOIH; this patient subsequently had a "good" recovery. Overall, the absence of renal uptake in 24 patients in the 2 studies was associated in 20 instances with end stage renal disease or death. It was suggested that the assessment of renal uptake of ~mI OIH in patients with severe renal failure helped predict recovery of renal function. 6,s Further review of the data suggest that the assessment of renal OIH uptake did not add to the prognosis based on the clinical diagnosis-patients with acute renal failure did well while those with chronic renal failure or renovascular occlusion did poorly. The poor prognosis of patients with chronic renal failure and nonvisualization on )a~I OIH scanning was confirmed by Sherman and B[aufox who reported that all 16 patients with this finding required chronic dialysis within 6 mo of the scan. 22'23 Caution in the interpretation of the O I H scan in patients with no significant renal function is necessary. Early images may show splenic activity while somewhat later images may demonstrate hepatic activity which can be mistaken for left and right renal uptake respectively. Early uptake i s based largely on organ blood flow; maximum uptake in poorly visualized kidneys would be expected to be a late occurrence22 (Fig. 2). Harwood et al. confined their study of the predictive value of ~31I OIH imaging to patients with a clinical diagnosis of ATN. 7 After 6 mo the 10 patients with a "prominent" renal uptake had a mean creatinine clearance of 80 ml/min while
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the clearance of seven patients with a "faint" uptake was 39 ml/min and that of seven with no renal image apparent was 25 ml/min. Three patients in the no renal image group required chronic hemodialysis while none did so in the prominent renal image group. The prognosis of the three groups could not be determined fully from clinical and laboratory data alone (Fig. 3). Cortical necrosis has been suggested as a likely explanation for the absence of renal OIH uptake in patients with the clinical diagnosis of ATN. 6 This was indeed the finding in 2 of 3 autopsy studies in such patients with this finding on renal scanning. 23The hepatorenal syndrome 6 and renal arterial occlusion 6"s also have been found in patients with acute renal failure and no kidney uptake of ~3~IOIH. Acute renal failure in the patient with a dissecting aneurysm of the aorta may result from renal arterial involvement or from A T N due to renal ischemia or the use of radiocontrast agents. Substantial renal blood flow apparent with 99roTe DTPA or pertechnetate scanning, or prompt uptake of 13tI OIH with delayed excretion suggest ATN and obviates the need for more invasive studies. Renal blood flow in ATN has been shown by Hollenberg et al. (using a 133Xe washout technique) to be reduced to approximately one-third of normal. 24The hepatorenal syndrome, zS"z6cortical necrosis z4"27and renal arterial occlusion z8 may be confused with ATN clinically but differ pathophysiologically in that extreme reduction in renal blood flow is characteristic. This difference in blood flow may be recognized by qualitative radionuclide determination of renal blood flow:9'3~or with a noninvasive 3t-33 or invasive 34'3s quantitative evaluation. The "nuclear filtration fraction" has been advocated by Schlegel and Lang as a diagnostic aid in acute renal failure. 36 The glomerular filtration rate (using 99mTC DTPA or 99roTe iron ascorbate) and renal blood flow (using ~3q OIH) were estimated based on 1-2 min renal uptake of the radionuclides) 7"3s The "nuclear filtration fraction" (glomerular filtration rate divided by renal blood flow) was found to be increased in ATN, decreased in "pre-renal" states and normal with postrenal obstruction. Though using this pseudo-filtration fraction is an intriguing approach felt by these workers to have a "high
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Fig. 1A.
See caption on t h e following page.
sensitivity (95%) for identification of A T N " data adequate to evaluate this claim are not available.
Acute Pyelonephritis Impaired renal function due to acute pyelonephritis is unusual but may be found if the infection is severe, 39 is associated with necrotizing papillitis, or if it complicates underlying chronic renal disease. 4~ Before one can attribute an acute decline in renal function to a urinary tract infection evidence of renal involvement (rather than infection of the bladder alone) must
be present. A typical setting in which this determination may be valuable is in the patient with chronic renal failure and an indwelling bladder catheter who develops fever and an acute decline in renal function. Nuclear medicine studies may help differentiate upper from lower tract infection. Preliminary evidence suggests that renal imaging with 99mTCDMSA or GH may be useful for this problem 41 but 67Gahas been more extensively studied. Hurwitz et al. used 24-hr gallium imaging in 49 patients who had pyelonephritis confirmed or excluded by conventional testing (including 26 examined by invasive methods). 42Among 25 with
NUCLEAR MEDICINE IN RENAL FAILURE
269
0-3
rain.
131I-Hippuran
6'9
m-rn.
Fig. 1. The typical contrasting pattern of 1311 OIH uptake in ATN and chronic parenchymal renal disease is illustrated. In ATN, uptake is rapid and excretion is delayed or absent. In chronic renal disease, uptake is poor but definite urinary activity is usually present in the bladder. (A} Acute tubular necrosis in a renal transplant. ~ T c - D T P A and 1311OIH studies are shown. Initially, on day 1, perfusion and uptake of the radiolabeled orthoiodohippurate are both somewhat diminished but still present. No significant excretion of the radiolabeled orthoiodohippurate into the bladder is noted. During the subsequent days of study, improvement in perfusion, uptake and excretion of ~31101H are demonstrated, suggesting recovery from acute tubular necrosis. (B) A 42-yr-old hypertensive male patient with history of chronic renal failure (BUN 79 mg/dl, creatinine 5.3 mg/dl). 1311 OIH renal scan demonstrates diminished renal function in both kidneys. Four hour delayed study excludes the evidence of significant postrenal obstruction. Note that both kidneys are smaller than normal and bladder activity is definitely present.
demonstrated upper tract infection 22 had renal uptake of gallium while 4 of 24 with lower tract infection had falsely positive exams. Renal gallium uptake was not normally found at 24 hr by these workers; this contradicted other reports. 43-45 Differences in imaging techniques are the most likely explanation for this discrepancy. Detection of the multiple photopeaks of 67Ga, use of multiple windows with thick septa, middle or high-energy collimator and tomographic capabilities all enhance 67Gaimaging. 46 With current
technology renal images may normally be seen as late as 48 hr after injection. 47 Regardless of technique, renal gallium uptake which increases from the 24 to the 48 hr scan, 43is unilateral, focal or as intense as that of the liver is abnormal. 47 Gallium scanning is a promising, noninvasive method that may aid in the recognition of renal functional deterioration due to pyelonephritis. In addition, the procedure appears useful in localizing renal infection in patients with chronic renal failure due to polycystic kidney disease. ~5Its use
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Fig. 2. (A) Liver and spleen uptake of 13~101H and m"Tc labeled renal agents in advanced renal failure. Posterior scan of the kidney w i t h ~1 OIH (top and b o t t o m left) and of the liver w i t h m"Tc-suIfur colloid (bottom right). Renal scan obtained after the administration of 200 uCi of 13~1OIH and a liver scan after the administration of 2 mCi SS'Tc-Sc. In the 0-3-min exposure (bottom left), a significant accumulation of radioactivity is apparent in the right upper quadrant, corresponding to the area occupied by the liver. Some activity can be noted on the left which approximates the region of the spleen and could easily be mistaken for the left kidney. On the 12-15-min view (top), the activity on the left is essentially cleared but there is still some suggestion of residual activity on the right which could be mistaken for a right kidney. (From Nephron 25:82-86, 1980.) ( B - - P a r t 1 ) A 70-yr-old w o m a n w i t h history of breast carcinoma became azotemic (BUN 70 mg/dl, creatinine 10 mg/dl). The patient complained of bilateral flank pain. To assess renal function and evaluate the possibility of obstructive uropathy, m"Tc-DTPA renal perfusion study and ~311OIH renal scan w e r e performed. Sequential 2-sec images of renal perfusion study demonstrated early m"TC-DTPA activity in the left renal area (arrow) which subsequently was proven to be a spleen. ( B - - P a r t 2) The spleen (arrow) could be easily mistaken for the left kidney. S'~Tc-DTPA activity in the upper quadrant on dynamic and early static phase (1-2-rain bottom left) was liver activity which could be mistaken for the right kidney. One hour delayed S~Tc-DTPA study (top left) reveals somewhat enlarged right kidney. Organ identification is aided by the accompanying sulfur colloid scan (bottom right). ( B - - P a r t 3) ~S~lOIH renal function study (A-C) reveals no left renal activity and very poor right renal function. A, right upper quadrant activity is from liver. B and C, liver activity cleared and delayed right renal uptake seen. One hour delayed m"Tc-DTPA renal scan also demonstrates poor right renal function (D). Within 48 hours, ultrasonographic study of the kidneys confirmed atrophic left kidney and right hydronephrosis with 2-cm renal cortical thickness.
NUCLEAR MEDICINE IN RENAL FAILURE
271
Scan
Nonvisualization
Ultrasound
Study
No Obstruction
Obstruction
J J J
potential recovery of renal function with surgical relief
Fig. 3.
Bilateral Normal Size
Bilateral
Asymmetric
Small Size
Size
substantial to total impairment of renal function at 6 months
dialysis needed within 6 months
potential reversibility exclude vascular occlusion
Evaluation and prognosis of renal nonvisualization with lall OIH.
is discussed more fully elsewhere in this issue in the article by Handmaker. Acute Interstitial Nephritis Recognition of acute interstitial nephritis (noninfectious) may be easy when the characteristic features are present but more difficult when many of these features are absent and ATN is easily misdiagnosed. 49 Wood et al. first noted the intense, diffuse 48-hr uptake of gallium in three patients with biopsy evidence of this disorder: ~ Linton et al., reporting on nine patients with acute interstitial nephritis due to drugs, described the same finding on gallium scanning. In addition, they studied patients with other renal disorders including six patients with ATN in whom there was no uptake of the isotope. They suggested that gallium scanning may help distinguish patients with acute interstitial nephritis from those with ATN.49 Renal gallium uptake is not uniformly absent in ATN. George et al. described 12 patients with renal transplants and ATN whose kidneys accumulated the isotope# l Kumar and Coleman reported three patients with ATN two of whom
were renal transplant patients) 2 The extent and intensity of the renal uptake was not described in either report. Though ATN is frequently listed as a cause of renal gallium uptake 15'44other reports of this observation in patients other than recipients of a renal transplant are scarce. 43 Impaired renal function has also been suggested as a cause of delayed (beyond 24 hr) renal visualization with gallium 43 but evidence to support this contention is lacking. The evidence to date suggests that gallium scanning is a useful means of differentiating acute interstitial nephritis from ATN, particularly when urinary tract infection is absent and renal uptake is diffuse and intense (Fig. 4). Renal Artery Embolism Renal artery embolism should be considered as a cause of acute renal failure particularly in patients with atrial fibrillation or acute myocardial infarction. Radionuclide studies can play a major diagnostic role in this disorder. Early reports on patients with renal artery embolism noted the good correlation of 99rnTc pertechnetate flow studies with renal arteriogra-
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]
..............
.....
Fig. 4. (A) A 45-yr-old female patient presented with an acutely rising BUN (71 mg/dl) and creatinine (5.5 mg/dl), Clinical diagnosis was strongly suspicious for acute interstitial nephritis. Slightly delayed lSll OIH concentration and markedly delayed excretion is noted in both kidneys. Twenty-four hour renal scan demonstrates significant tracer excretion from the kidneys making obstruction unlikely. Each view illustrates 3-min sclntiphoto. Renal ultrasonogram showed normal renal size without obstruction. (B) Posterior view of STGallium-citrate renal scan at 48 hr. reveals substantial radiogallium concentration in both kidneys.
phy. 29'53Lessman et al. reported on 17 cases with renal artery embolism 15 of whom had acute renal failure.54 99mTc pertechnetate perfusion scanning showed unilateral or bilateral absence of renal blood flow in nine of ten cases studied and the remaining patient had bilateral perfusion defects. In the eight patients who also underwent angiography the findings were virtually identical. Even when renal artery embolism does not completely interrupt renal blood flow, renal failure may occur in association with multiple parenchymal infarcts. 13zI OIH was diagnostic in this situation in a patient with endocarditis and renal failure.6 More recently 99mTC DTPA, 55 99mTCGH 15and 99mTcDMSA 12'13have been used and advocated for recognition of this problem. When the diagnosis of acute renal failure due to renal artery embolism is under consideration, renal scanning may be of considerable value in
recognizing as well as excluding the diagnosis.6"53 Arteriography may not be necessary unless there are plans for surgical intervention3'54'56 (Fig. 5). OBSTRUCTIVE NEPHROPATHY
Isotopic scanning techniques appear suitable for demonstrating urinary tract obstruction in patients with relatively normal renal function,s7 Since visualization of the collecting system depends on glomerular filtration and/or tubular secretion renal insufficiency must, to a varying extent, impair the sensitivity of kidney scanning for recognition of hydronephrosis. Despite this basic difficulty scanning may be useful in patients with renal insufficiency and urinary tract obstruction and has been advocated for diagnostic use in this setting} '57 When routine studies are inconclusive in the patient with possible obstructive nephropathy delayed imaging will often produce useful mor-
NUCLEAR MEDICINE IN RENAL FAILURE
273
Fig. 5. (A) A 74-yr-old man was admitted to the hospital with a pulsatile abdominal mass. The patient had history of right nephrectomy for renal calculi performed 24 yr ago. Retrograde femoral aortogram reveals large aneurysm of lower abdominal aorta. Solitary left renal artery is visible (arrow). (B) Scintiphotographic studies w e r e performed for oliguria which developed after placement of an aorto-iliac by-pass graft. A, posterior lSTHg chlormerodrin study fails to reveal any renal activity. S-D, m"Tc-pertechnetate study fails to show any kidney perfusion. Aortic surgical site is seen as defect in isotope column (arrow). E-F, 131101H study fails to reveal renal concentration, suggesting renal artery occlusion rather than ATN or dehydration, other diagnosis which were considered. (C) Repeat aortogram shows occlusion of solitary left renal artery (arrow). Surgical clips from by-pass graft aortic operation are apparent. An embolic atheromatous plaque was removed at surgery. (From J Urol 105:473-481, 1971.)
phological information. 2'6'57 When substantial renal insufficiency is present and imaging beyond 24 hr is contemplated, 1311OIH may be superior to 99mTC chelates 57 due to its longer halflife. Malave et al. studied 56 patients with suspected hydronephrosis, half with renal failure, using 131IOIH and 99mTc DTPA. 5s Images were not obtained beyond one hour for DTPA or 30 min for OIH. In 1 I% a false positive diagnosis of hydronephrosis was made while in 26% the results were inconclusive as a result of poor renal uptake of the isotopes. Scanning was felt to be accurate only with normal or moderately
impaired renal function but was useful regardless of the degree of renal impairment in following interval changes in the function of the obstructed kidney. Absence of renal uptake of 131IOIH in patients with obstructive nephropathy does not preclude substantial recovery of kidney function. This applies to both unilateral 59'6~ and bilateral obstructive disease. 61 The use of ultrasound to detect urinary tract obstruction has increased dramatically in recent years. While highly sensitive in the detection of hydronephrosis a substantial false positive rate (26%) has been reported. 62 With improving
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equipment and diagnostic criteria better specificity has been noted58'63 but the further evaluation of patients with dilated collecting systems may present problems if, as with chronic renal failure, 64 avoidance of intravenous contrast media is desirable. Diuretic radionuclide renography may help differentiate a dilated obstructed collecting system from one which is dilated but has no mechanical obstruction.65~8 Renal retention of the administered radionuclide occurs with hydronephrosis regardless of the presence or absence of mechanical obstruction due to dilution of the isotope in the large collecting system volume with a lower isotopic concentration per unit volume of urine passed into the bladder. The unobstructed hydronephrotic kidney should respond to diuretics with an increased urine volume and radioisotope clearance; the mechanically obstructed kidney is unlikely to respond. 66 This methodology is discussed in detail in the article on obstructive uropathy in this issue. In patients with renal failure66this method can be applied successfully if the collecting system is adequately visualized and a diuresis achieved. Measurement of urine volume following the diuretic injection may be helpful69 as may increasing the dose of furosemide. While an obstructive pattern may reflect poor renal function, a dilated, nonobstructive pattern will still effectively rule out mechanical urinary tract
obstruction .66 CHRONIC RENAL FAILURE Chronic Pyelonephritis
Recognition of chronic nonobstructive pyelonephritis in the adult may be difficult since a positive urine culture and pyuria are nonspecific and the "classical" changes on urography (calyceal blunting and deformity with depression of the overlying cortex) are seen most commonly in childhood as a result of vesicoureteral reflux, v~ Adults with pyelonephritis may have advanced histologic damage without apparent abnormality on urography.7! Davies et al. used 19VHg chloromerodrin to study 50 patients with the clinical diagnosis of chronic pyelonephritis and normal urography.72 Despite the poor image resolution that was possible with the agent and equipment used, localized renal defects were seen in 10 patients.
McAfee reported on 31 patients with chronic pyelonephritis (seven with renal insufficiency) who underwent urography and renal scans with 99mTc GH and 131I OIH and had abnormalities in one of these studies. 73Although the overall sensitivity to renal morphologic abnormalities was greater with urography than with scanning, focal parenchymal damage was better seen with nuclear imaging in eight patients and GH was more useful than OIH. As might be expected 99mTc DMSA also has been reported to facilitate assessment of cortical scarring in pyelonephri-
tis.9,15,16 Unlike urography, renal scans can demonstrate intraparenchymal abnormalities which do not deform the collecting system or renal outline. Nuclear imaging may therefore be a useful supplement to urography for detection of renal damage due to chronic pyelonephritis. Active renal infection may, however, result in scanning defects which resolve with timefl '72 Chronic pyelonephritis (as well as renovascular disease and unilateral obstruction) may result in asymmetric renal damage unlike glomerular disease or nephrosclerosis which tend to cause symmetrical dysfunction. Recognition of differences in radioisotope uptake may, to a minor extent, aid in recognition of these disorders. 74 Reflux Nephropathy
Reflux nephropathy, recognized as an importent renal disorder in children, has been increasingly recognized in adults as a cause of hypertension, proteinuria, and renal failure that may progress to end-stage renal disease. 75'v6 The direct radionuclide voiding cystourethrogram (VCU) (using suprapubic puncture or bladder catheterization) is useful for the detection and follow-up of patients with clinically significant vesicoureteric reflux, vv'v8 Though it is often used in children to minimize radiation exposure it may be used in adults. The intravenous radionuclide VCU is an attractive noninvasive method for detecting reflux v9 but, because of the prolonged excretion of the isotope, is not recommended for use in patients with renal insufficiency, s~ Recognition of reflux despite renal failure may be possible using the computer analysis described for diuretic radionuclide renography.66
Fig. 6. (A) A 30-yr-old female with hypertension. Physical examination revealed bruit in right flank. IVP was normal and digital radiographic study of the kidneys appeared normal, m"Tc-GH and 13~1OIH renal scan w e r e done because of persistent hypertension which was refractory to therapy. An early dynamic renal study (m"Tc-GH 6 - 8 sec.) demonstrates asymmetry of renal perfusion w i t h diminished right renal blood f l o w and 2 hr static image shows reduced right renal size with some segmental loss of cortex while left kidney shows normal size and contour.
Angiographic study reveals normal left renal artery but right renal artery demonstrates flbromusuclar dysplasia (arrow). (B) Transluminal angioplasty was done. Note preoperative lS~l OIH renal scan with delayed right renal tracer concentration and excretion. Cross-over sign compatible w i t h renovascular disease is seen on renogram curves between right and left kidney prior to angioplasty. Postoperative seventh day :Sll OIH renal scan shows improvement of right renal function.
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Renal Lymphoma Renal insufficiency is a common complication of malignant lymphomas and results from hypercalcemia, uric acid nephropathy, glomerulopathies, dehydration, urinary tract obstruction, amyloidosis, or, in 12%-14% of patients, 81 lymphomatous infiltration of the kidneys. Gallium scanning will detect lymphomatous organ involvement, including that of the kidney, 82 with a sensitivity of from 30 to more than 75% depending upon the imaging equipment used and, possibly, the histologic class of the lymphoma.83 Gallium scanning may be of value in evaluating the patient with lymphoma and renal failure. A multinodular pattern of renal involvement, detectable on scanning, 84 is 10 times more common at autopsy than diffuse involvement,8~ making the pattern of gallium uptake useful. Urography and ultrasound may be unable to differentiate renal cysts from lymphomatous nodules. 84 More studies of gallium scanning in renal lymphoma are needed before the actual value of the exam can be assessed. Renal Artery Stenosis Renal artery stenosis, in addition to its role in hypertension, is an important, potentially treatable cause of renal failure. It has become increasingly recognized that even prolonged vascular occlusion does not preclude successful repair of the stenosis with recovery of renal function, ss As with renal artery embolism, radioisotope scanning with 99mTCpertechnetate or DTPA has been used to assess renovascular patency with a high degree of accuracy. 2s,86 The absence of perfusion on flow studies is not diagnostic of complete vascular occlusion but the additional observation of no uptake of OIH indicates an essentially nonperfused kidney, g7 More sophisticated techniques that allow noninvasive, quanti-
tative assessment of renal blood flow 31-33 also may be of value in this setting. Percutaneous transluminal angioplasty is currently felt to be indicated for renal failure due to renal artery stenosis s8 and has been successfully used in patients with this disorder. 89'9~Radionuclide studies may be of benefit in evaluating the success of "balloon" angioplasty as well in recognizing complications from the procedures (Fig. 6). Born et al. 91 used 99mTCpertechnetate, 131I OIH and 99mTCDTPA to demonstrate improved renal function in three patients following angioplasty. Kuhlmann et al. studied eight patients with renal artery stenosis, hypertension and, in half the cases, renal insufficiency who were treated with percutaneous transluminal angioplasty. 92 All those with impaired kidney function improved with restoration of renal blood flow. Measurement of renal plasma flow using 13tI OIH clearances with determination of individual kidney components utilizing a computer-linked gamma camera were undertaken prior to and every 2 mo during the 6-month follow-up period. Both vascular complications of the angioplasty (occlusion of a renal artery and the development of a slight renal artery restenosis) were suspected on the basis of the isotope studies and confirmed angiographically. Serial isotopic measurements of renal plasma flow were felt to provide a good, noninvasive method for evaluating the effects of the vascular procedure. A thorough understanding of the wide variety of conditions in which radionuclide imaging can be achieved is essential to its use. In the patient presenting with renal failure, a planned logical approach may prove of considerable value to the clinician in the differential diagnosis and prognosis of the patients' illness. ACKNOWLEDGMENT
The excellentsecretarial assistance of Donna MacGregor is gratefullyacknowledged.
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