RADIOISOTOPE LOCALISATION FOR RENAL BIOPSY

132

RADIOISOTOPE LOCALISATION FOR RENAL BIOPSY NANCY TELFER M.D. Woman’s Medical College, Penn. CHIEF, OUTPATIENT DEPARTMENT; ASSISTANT PROFESSOR

OF MEDICINE

ALBERT E. ACKROYD

STANLEY L. STOCK

M.D. Minnesota

M.D. Southern California CLINICAL INSTRUCTOR

CLINICAL INSTRUCTOR

From the Department of Medicine, Los Angeles County Harbor General Hospital, Torrance, California, and University of California School of Medicine, Los Angeles

Fig. 10-Operation for defect of fibula.

successful in mild cases seen early. Most opinion, need early surgical intervention.

patients, in our

A

prosthesis works well in below-knee amputees and satisfactorily in above-knee amputees. As a replacement of the upper extremity an artificial limb is practically only of cosmetic value; in phocomelia its functional possibilities are even poorer, because muscular power is often very weak. Even a very deficient hand with normal sensibility is functionally superior to a prosthesis. In a phocomelic limb muscular power and function can often be improved if the unstable extremity is surgically given bony support and useful direction. In some limbs the new position can be adapted to the defect-e.g., transposition of the clavicle shortens the distance between the shoulders, which makes it easier for the patient to use the short upper extremities together. Finally, an artificial limb can always be fitted later if so desired, and it will have a better power source after this type of operation. The final disablement caused by congenital bone defects depends on the anatomical and the psychological condition of the patient. It is evident that a severe defect can be greatly compensated by favourable mental qualities. The aim of treatment is a self-supporting member of

society. infant should be treated at This principle applies to all psediatric surgical patients, but perhaps is even more important in the treatment of crippled children. Initially the parents of severely malformed babies are often unwilling to take care of them at home. The isolation of such badly crippled infants and children in special nurseries or hospitals may result in emotional disturbances and is not in accord with the trends of modern psychology. The unwillingness of the parents soon disappears as the child grows. Attempts to improve the shape and function of the malformed limbs are often eagerly demanded by parents. Leaving the patients without any treatment or merely fitting them with routine orthopaedic appliances tends to induce a feeling of hopelessness in the parents. We are convinced of the advantages of early active surgery, because (1) malpositions can then be corrected very much more easily than in advanced cases, and secondary contractures can be avoided; (2) muscular function can often be improved; (3) the stay in hospital is shorter; and (4) parents are made more hopeful and treatment at home becomes feasible. There is no doubt that home so far as possible.

an

IN this age of increasingly numerous and complex laboratory studies, any simplification of an existing pro. cedure is desirable, especially if it increases the probability of success and decreases the discomfort of the patient. Hence, we decided, before subjecting patients to renal biopsy, to try to outline the position of the kidneys accurately and rapidly by means of radioactive mercury (203Hg). This was based on the ability of the kidney to concentrate an intravenous dose of this radioisotope. Routine tests,

as

well

as

renograms and intravenous

pyelograms, performed exclude anatomical lesions, such as polycystic kidneys, which might contraindicate renal biopsy.. At first, the biopsies were done after the position of the kidneys had been defined by scanning. (McAfee and Wagner 1960). This meant that the radioisotope laboratory had to be notified in advance. The patient was taken to the laboratory on the day of examination and given the scan dose of 100 f-LC of 203Hg intravenously. This dose has been estimated to deliver 50 rads to the kidneys. Forty-five to sixty minutes were needed for the renal tubules to concentrate the mercury. Next, the patient was placed on his abdomen, and the kidneys were to

were

scanned under thePicker’ automatic scanner; this took another forty-five to sixty minutes. The outline of the labelled kidneys was traced on the patient’s back by means of the visible light target from the scanner. Although this procedure localised the kidneys for the biopsy, it was time-consuming and cumbersome. Our technique now entails very little technical

preparation. syringe filled with 10 f-LC of 203Hg (’ Chlormerodrin’, Squibb), in sterile physiological saline solution from the radioisotope laboratory. This dose is onetenth of the dose required for scanning. This is then injected intravenously about forty-five minutes before the biopsy is to be done. The patient may be taken to the ward treatmentroom or else left in his bed. He is placed in position for the biopsy, prone, with a sandbag or pillow under the abdomen to fix the kidneys. The two areas of greatest activity are located with a Reed portable scintillation detector, which consists of The operator obtains

a

1-in. thallium-activated sodium-iodide crystal shielded by 1/2-in. lead. The y-rays emitted from 203Hg are absorbed by the crystal, and the resulting photoelectric impulses are amplified by a photomultiplier tube and fed into a batteryoperated counting rate-meter. The entire detecting system is portable. Localisation requires only ten to fifteen minutes, and a

at

the

same

time indicates renal function

on

both sides. The

position of the kidneys is verified with an exploring needle, and the biopsy is done with a Franklin modification of the ’Vim-Silverman’ needle (Iversen and Brun 1951, Kark and Muehrcke 1954).

Sulamaa, M. (1960) Acta chir. scand. 119, 194. — (1963a) Postgrad. Med. J. 39, 67. (1963b) Clin. Pediat. 2, 251. Ryöppy, S. (1963) Acta orth. scand. (in the press). —

—

133 We have used this technique in 11 patients; in 9 we obtained enough tissue for diagnosis. Of the 2 failures, 1 was in a patient with chronic renal failure who had been on intermittent peritoneal dialysis for the three weeks preceding the biopsy. He had virtually no kidney function, and hence the renal tubules did not fix the mercury. The other failure, in a patient who hadgout and probable uric-acid nephropathy, is more difficult to explain. There was good concentration of the mercury, and both the exploring needle and the biopsy needle showed excellent excursion with respiration, indicating that they were in the vicinity of the kidney. But fat only was obtained. The renal parenchyma may have been the entrance of the needle. The

only observed

too

firm

after-effects have been

to

permit

microscopic

hsematuria in 10 patients, and back pain lasting

two to

three days in 5 of the patients, which is no different from the after-effects in other localising procedures. The advantages of the new method are:

RADIOMIMETIC TOXICITY OF OZONISED AIR R. BRINKMAN M.D. PROFESSOR

T. S. VENINGA

H. B. LAMBERTS M.D.

From the Laboratory of

Radiopathology, University of Groningen, The Netherlands

FIVE years ago Brinkman and Lamberts (1958) drew attention to the possibly radiomimetic effects of exposure to ozonised air. Although this was confirmed in several ways (Freebairn 1957, Fetner 1958, 1962), and especially by Fetner, who demonstrated that chromosome breakages in human cell cultures exposed to 8 p.p.m. of ozone for 5 or 10 minutes are equivalent to those produced by 200r

1. The biopsy can be done in the ward. This helps to allay the patient’s apprehension, which is usually magnified when he is moved from his own ward.

2. The

may be done on the same day the patient the procedure. This serves to emphasise the of the procedure, and to lessen the patient’s

biopsy

consents to

simplicity concern.

3. The person doing the biopsy is independent of any other service, except that of the radioisotope department. If, for any reason, the doctor cannot do the biopsy on the day of the injection, it can be done at any time during the next few days,

using the originally injected dose of 203Hg. 4. With isotope localisation the function of both kidneys can be ascertained at the time of biopsy. 5. The patient is placed in position for biopsy before the localisation procedure. This is not possible if one uses X-rays for localisation. We are satisfied that placing a sandbag or pillow under the patient’s abdomen not only helps to fix the kidneys, but may raise them several centimetres. If this shift is taken into account-and it is not apparent with the usual intravenous pyelogram-the lower pole of the kidney could be missed. 6. The procedure can be adapted to variations in the patient’s kidney function and body habitus, and the hospital’s available equipment. As an example, a patient who was 5 ft. 3 in., and weighed 240 lb., and who, at the time of the biopsy, had a blood-urea-nitrogen of 95 mg. per 100 ml. which was still rising, was given the full 100 fLC dose; several hours were allowed for the poorly functioning kidneys to fix the mercury, and she was taken to the radioisotope department to use the more efficient detection equipment. We were unable to use the automatic scanner, since the patient could not lie on her abdomen for more than thirty seconds without becoming extremely uncomfortable; also, she did not fit under it. Consequently, the position of the kidneys was outlined with the patient in a sitting position, and the biopsy was performed in the same position. not

Fig. 1-Grey male mouse. a=4 hr. in 0-2 p.p.m.

b =2 hr. in 0.2 p.p.m. c =control.

ozone.

(250 kV), no notice of this potential danger was taken by public-health authorities. Apart from other considerations, the great increase in the usage of commercial ozonisers prompts us to communicate new observations on the radiomimetic consequences of exposure to very low " non-toxic " concentrations of ozone. To our knowledge ozone toxicology has been restricted to the acute irritation of airway mucous mem-

Summary A simple, easily adaptable method of outlining the position of the kidneys for renal biopsy consists in the intravenous injection of 10 fLC of 203Hg (’ Chlormerodrin ’) and localisation of the radioactive mercury in the kidneys by means of a portable scintillation detector. .

We would like to express our appreciation to Dr. Franz K. Bauer for his advice; and to Dr. DeLores E. Johnson and the radioisotope department for their cooperation and counsel. REFERENCES

Iversen, P., Brun, C. (1951) Amer. J Med. 11, 324. Kark, R. M., Muehrcke, R. C. (1954) Lancet, i, 1047. McAfee, J. C., Wagner, H. N., Jr. (1960) Radiology, 75,

Fig. 2-Young 820.

ozone.

rat.