Scintillation Scanning in Renal Disease

April 1962 & Wilkins Co.

SCINTILLATION SCAI\NIXG IN RENAL DISEASE ROBERT D. WE8TPHAL,* RUSSELL SCOTT, JR., ETHEL E. ERICKSO?\ AND

DONALD MOTZKIN

from the Departrnerds of Medicine, Urology and Pathology of Baylor Umversily Col/eye of !Vledicine and the Veterons Administration Hospital, Houston, Texas

Problems arise in the diagnosis of renal disease beeause of limitatiorrn inherent in the method of examination or because of the peculiarities of th(-; pathologic procc'.ss. Diagnostic roentgenogrnphie proeedures such as excretory and retrograde pyeJography yield invaluable information about the anatomy of tlw !'ollecting system but contribute limited information about the functional capacity of the parenchymal portion of the kidney. This is especially true in segmental renal disease. Split renal fundion studies give some information about the total functioning of an entire kidney but no information about [\mdion in limited areas of a kidney with segmental disease. The renal augiogram details in a precise way the size and course of the renal artcries 1 but contributes no information about function of the parenchyma. The renal biopsy i~ a valuable diagnostir, procedure which may provide a speeific diagnosis if the biopsy is obtained from the diseased area. ~\fore recently, the rcnogram has been used to detect unilateral renal disease and provides some information about the vascular supply and functional capacity of an entire kidney, but this tcchniq ue does not supply information about segmental renal disease or segmental function. ,,Then one utilizes all available rnethods of examination in a single patient, the undertaking becomes formidable. Therefore, there is need for a simple and safe procedure which can delineate changes iu the functional capacity of various areas of a kidney. The initial goal of our study was to develop a technique which would delineate renal parenchyma and detect arens of non-function suspected of harboring a renal neoplasm. To be of greatest value to the patient, detection must be accomplished before the occurrence of vascular invasion, dissemination of metastases, or distortion of the pyelographic pattern. In the course of our pre-, liminary work, it was aµparent that the method would prove valuable in the diagnosis of other Accepted for publication October 3, 1961. * Present address: VA Center, Bay Pines, Fla.

519

diseases of the kidney such as pyclorn'.phritis and congenital anomalies. In this paper the that has evolved is described and fine illustrnti,,e case studies are presented. The technique of renal scanning is the same as that applied to the
Renal scans are perforrned without preparation of the patient. The patient lies prone position while the radiation. det,'.dor plots the location of radioactivity in Uw areas. Iodine I-131 labeled hippuran salt of ortho-iodo-hippuric acid) is intravenously in doses of eight microeurie2 kilogram of body weight. Scanning is approximately one minute after the

520

WESTPHAL AND ASSOCIATES

l l I

I

I I

I

I!

I I

11

,,

l I l

!

I

I

I t

I

I ll l

i'

l

! \

I

l 11 l I I

I

l

I

I

1 I

1, I

]

,,

I

I I

'

I

! I I

FIG. 1

requires 20 minutes to traverse both renal areas. Following scanning the patient is instructed to force fluids orally for 3 hours. Details of the electronic system, recording device and radiation dosage have been reported previously.1 From the standpoint of radiation exposure, the procedure is safe. A patient with a normal blood urea

nitrogen level will receive only one-fifth to onetenth the total body radiation exposure that is incurred in performing an excretory urogram. In addition, the quantity of organically-bound iodine is so minute that the risk of an allergic reaction is practically non-existent.

~ Westphal, R. D., Risser, J. R., Motzkin, D., Erickson, E. E. and Morgan, M. C.: Delineation of human kidneys by scintillation scanning. Am. J. Roentgenol., in press.

One hundred and thirteen renal scans have been performed in 87 patients. We would like to discuss several scans together with other clinical

RESULTS

SCC\!TILLATIO_:\, SCANNIKG IN RENAL DI:-:EASE

data of patients with tumor deformities, calculus dis<'ase, ]Jydonephritis and c,ongenital anomaly. Case l: A 39-year-old man was admitted following several homs of sc\'ere left flank pain similar to that which he had had intermittently for I5 years. Sonwtimes he had fever and hematuria as well. A diagnosis of left renal calculi had been established prc\'iously. The admission blood JH'cssure was 150/100, temperature 99F. Physical examination ,vas not remarkable except for left costcfferkbrnl angle tenderness and left lower quadrant guarding and tenderness. The white blood c,cl] count was 7650, hemoblobin 1/j gm. per eent and the hematocrit 50 per c:ent. Tl1e grossly bloody urme contained 2-plus albumin with microscopic findings of 30 to 35 red blood cells and 6 to 10 white blood cells per high power field. The scrum calcium was 10 mg. per cent and the phosphorus 3.8 mg. JWI' cent_ The blood m·rn nitrogen was 19 mg. per cent. A stained snwat· of the, urinary sediment showed m1mrrous cells but no bacteria. Urine culture was of no assistanc:r. An cxnctor_1-

I I I

I

I

I

I I I I I

I

urograrn (fig. l, "1) revealed multiple-, opaq11F, stones in the left kidney arPa along with poor excretory function. Retrograde pydography (fig. 1, B) disclosed opacities in the left lower pole and a small contracted collecting systen1. An enlarged upper calyx repreRented either :1 calyceal diverticulum or an abscess cavity. Tlic renal scan (fig. l, C) revealed marked climinution in the mass of functioning tissue on the left with the majority of the radioacti,-ity concentrated in the, upper pole of the kidney. The size of the right kidney appeared normal hut some urn·n·nrn'ss of distribution of radioactivity was prrscnt. This was sugge,stive of the presence of nonfunctioning tissue on the left and to a. lesser extent on the right, compatible with probable episodes of pyclonephritis. Left tomy was performed. The kidney weighed 88 gm. and was urie\-c'nly scarred with the intervening Hnrfacrs The calyx in the upper pole wa8 dilated, 2.5 2.1 cm., lined with necrotic and hemorrhagic material and contained 5 calculi. Jiicroscopically

I

I I

I

Fm. 2

522

WESTPHAL AND ASSOCIATES

I

I

i' I

I

I

I

I I I

I I 1

I!

I

I

I I I I

I I ,1 ,

I

I

I I I I I I

I! Ii'

!

I I l I

I

I

I

!

i! I i' i'I U1\111 II I Ill

I

I

I

I

I I

I I

I 111li1,\

/

i' I

1,

Iii I I I ! I ! I I Iii lilt,111111111 ill i I! I I

I Ill! II 111111 JI I I I I I I i 111111 11111! ii i I I I i ! ! t 1 ! !l l I l I l I 1 ! I I I I I I ! Ill I II I I I I I I I I I I Ii I I I ! I I I I I I I I I I I I ! I I I I I I

I

I I I I I •111111111111111 I

I !

I

1

1 f I 1 Ii t I 11

!

I

'i

:

I

I

I I I I !Iii 11 I 11 I I I ii I !llilfi I I! I II I I I 1 11, 1i11:w111i,::w11:W1 11 1 : 11 I I I 111 llili!l li!llllll!ilili I I I I I

I 1

I

I I I I I ! II I i!il I I ! I

I

I

I •1 I 11 11

I

I I

I

I

I I

I I

I

I ! I I I I I I I I I I I I 1 I I I 1'' I I ,11 I I I

Fm. 3

there were hyalinized glomeruli in the scarred areas with the parenchyma infiltrated with lymphocytes, plasma cells and large mononuclear cells. These cells extended to the pelvis where the lining epithelium was extensively shed and red blood cells were present. The walls of the small arteries and arterioles were thickened and many of the tubules contained a homogeneous pink coagulum. The diagnosis of pyelonephritis, chronic and acute, with calculi was rendered. Case 2: A 49-year-old man, ill at least 4 months before admission, presented with pain in his hips and legs sufficiently severe to keep him in bed constantly. He also complained of profound muscle weakness. He had severe anorexia accompanied by a 30 pound weight loss. His temperature was 99F and the blood pressure 130/80. He was chronically ill, markedly emaciated and showed profound wasting of the lower extremities. The white blood cell count was 16,700, hemoglobin 11 gm. per cent and hematocrit 34.5 per cent. The urine contained a trace of albumin,

many bacteria, 20 to 30 white blood cells and 1 to 3 red blood cells per high power field. A stained smear of the urinary sediment revealed many cells and a few gram-negative bacilli. The first urine culture was negative at 96 hours but a specimen on the first postoperative day yielded coliform bacilli and Aerobacter aerogenes. Subsequently, Paracolobactrum aerogenoides and Escherichia coli were cultured from midstream urine. The excretory urogram (fig. 2, A) disclosed satisfactory bilateral function with a large renal calculus on the left side. Renal scan (fig. 2, B) revealed the presence of a defect in the left lower pole which corresponded exactly with the position of the opacity seen in the roentgenogram. Some unevenness of distribution of radioactivity was apparent throughout both kidneys and was suggestive of the presence of pyelonephritis. Left nephrolithotomy, resection of the lower calyx and biopsy of the upper pole were performed. Microscopically areas of hyalinized glomeruli with thickened capsules, and infiltration

SC1N'r1LLA'l'I0N SCANNIXG IY RENAL DISEASE

I I

I

1,1

i

I

I

I

I

I

I

I I I

I

I

I

I

I

I

I

I

I

I

I

I I

I

I I

I

I

I I

I

I

I

iI

I

I

I

I

I

I

I

I

I

I

!

I

',

I

I

I I

!.

I

I

I

I

I I

I

I

I I I I I I

i

I I I

I

I

I

I

I

I

I I

I I

I

I

Fm. '1-

lymphocytes, plasma cells and large mononuclear cells consistent with chronic pyelonephritis were noted. Further investigation established a diagnosis of carcinoma of the lung as the cause of his debilitated state. Case 3: A.. 66-year-old man re-entered the hospital with a 12 year history of intermittent, gross, painless hematuria of undetermined etiology. On two previous admissions the presence of horseshoe kidneys was suspected. On this admission his temperature was 99F and his blood pressure 140 /90. The only pertinent physical finding was a slightly enlarged prostate. Laboratory determinations showed a white blood cell count of 7,500, hemoglobin 14. 9 gm. per cent and hematocrit 46 per cent. Serum creatinine was 1 mg. per cent. bloody urine contained 3-plus albumin and microscopic examination revealed numerous red blood cells. A stained

smear of the urinary sediment showed no bai:teria An excretory urogram (fig. 3_, revealed tlw presence of malrotation bilaterally Renal ~can (fig. 3, B) confirmed the abnormality of axes of both kidneys and the relative clown ward ment of the right kidney. Case 4: A 46-year-old man, known to polycystic renal disease since entered gross hernaturia and left flank pain which 24 hours before admission. He had bec·n talized numerous times in the past yearn with the same complaints. Physical examirrntion revealed a temperature of 99.4F, blood pressure 185/110 and the appearance of acute and chrome illness. Other pertinent findings were palpable kidneys with the left kidney tender. The admission hemoglobin was l 0.9 grr, per cent, henrntocrit :37 per cent. The urine contained 4 plus albumin and ou

524

WESTPHAL AND ASSOCIATES

examination was loaded with red blood cells. A stained smear of urinary sediment disclosed many cells but no organisms. A urine culture was negative. The blood urea nitrogen was 39 mg. per cent and the serum creatinine was 2.6 mg. per cent. An attempt to obtain an excretory urogram was unsatisfactory due to impaired renal function. An excretory urogram performed in 1954 prior to deterioration of function (fig. 4, A.) revealed enlargement and distortion of renal pelves and parenchyma compatible with the presence of polycystic disease. Renal scan (fig. 4, B) revealed multiple defects in the parenchyma, more severe on the right where almost the entire upper pole was involved. This satisfactory scan was obtained despite the impairment of renal function and with no absolute or relative increase in the amount of I-131 hippuran administered. Case 5: A 53-year-old man came to the hospital with a history of hesitancy, straining, small urinary stream, nocturia, dribbling 6 to 7 months in duration and intermittent, painless hematuria 3 to 4 months in duration. The temperature was 98.2F and the blood pressure 150 /90. The remainder of the physical examination was unremarkable. The white blood cell count was 10,000, hemoglobin 10.4 gm. per cent and hematocrit 36.5 per cent. The urine showed a trace of albumin and 10 to 15 red blood cells per high power field. The blood urea nitrogen was 17 mg. per cent and scrum creatinine 1.3 mg. per cent. A stained smear of the urinary sediment revealed some cells but no organisms. Retrograde pyelography (fig. 5) revealed a large tumor

deformity in the midportion of the right kidney. Following retrograde pyelography low grade fever suggested the presence of a urinary tract infection although pyuria or leukocytosis was absent. Antibiotic therapy was initiated and renal scan (fig. 6, il) was obtained 7 days after instrumentation. This disclosed an indefinite renal outline bilaterally that was indicative of poor function, more marked on the right. Renal scan (fig. 6, B), repeated 10 clays after cessation of antibiotics and 3 weeks after instrumentation, revealed marked improvement in that the renal outlines were now delineated bilaterally. It is to be noted that the same amount of I-131 hippuran was used to obtain the second scan. A defect in I-131 concentration was easily visualized, occupying the lower half of the right kidney. On surgical exploration and ncphrcctomy there was obvious tumor extending; throughout the parenchyma of the midportion of the right kidney (fig. 7). The kidney weighed 210 gm. On the posterior surface there was a white neoplastic mass, 6.2 by 4.5 cm. Microscopic examination revealed neoplastic columnar cells mounted on delicate fibrous connective tissue stalks that encircled varying sized spaces. A diagnosis of carcinoma was rendered. The finding of poor delineation of renal parenchyma in the first scan coincided with our experience in scanning patients with pyelonephritis and in this patient obscured the localization of a known tumor deformity. It is significant that within 2 weeks renal scan appearance reverted toward normal with the exception of the now delineated tumor defect. DISCUSSION

Frn. 5

It is evident from the scans and clinical data presented that renal scanning may become an additional valuable procedure for the urologist. As a result of our studies, we believe that pyelonephritis and diffuse vascular disease are indistinguishable in the renal scan. When definite abnormalities in the renal scan, clinical findings, pyelographic appearance and laboratory data are correlated, a more secure diagnosis may be established. In addition to lending diagnostic support, renal scanning permits study of pathogenesis of acute and chronic pyelonephritis, tumor deformity and congenital defects. It may,

SCINTILL,\TION SCA='iNING IN RENAL DISEASE l

I

l

II

i'

tI

I

II

I I

II

II i

11 / 11

III

II

J I t' I

I 11 ! I

I II I I 11 Ii I

I 11

I I

I I I

I

i I ff1 1111 11

11 I II I l

t 11 I 11 11 i I

,,

I I

I

I

I

I

I

!

I

I l

I

I

I

I

I

I I

I

I

l

I

I I

-r I

I

!

I I

I

I

I I

I

I

I

I

I I 11 I 11 I I I 1

I

I

I !

I

'

I

I I I I I l I I i 11 I I I I II! I

11 l

i

t'

I

I

I I I I I ! I I I

I I I! 1 I I I

i I I I'

i

I

l

I

I

I I I I I l II I I I! I t !, Ii I I! 11 11

I I

\

I l

I,

I

i

I

II I

I I

I

I

I I

I I

!

I

I I

I I I I! I1

I

I

I

I I i

I I

I

I i

I

I

I I I I

!

! I

I I

\ 1

1

I

!

I

!

I

1! I I I ! I

lu:. i'

l

I

I

I

I

I

i

I

!

1,

I I

I

I

I

I

I

I I !

I

I

!

I

I I

I

i

I

iii' t

i

J

i

1, I

\

f

it

I' I I

1i

1,

i

I I

I \

I

!

I

i i I

'1

1,

I

I

I

I

I

I

I

,I

I

I

I

I

I

I

i

I

!

I

FIG, fl

in tlrn ease of infections, ~-ielcl information on the ultimate prognosis of the disease. c\.t tbis stage in the clen:lopment of rrnal scanning, further study is nredecl to reso]yr some of thr trchnical problems, I-1:31 labrled hippuran

is rapidly conc:entratecl ancl excreted kidneys so that seanning must be rapidly and correctly on the; first attempt, Hm\·c;ver, we haYe preferrc;d to use 1-1:31 hip1rnran rather than materials retained for longer

526

WESTPHAL A:'i'D ASSOCIATES

FIG. 7

since the radiation dosage incurred by the patient is of such low magnitude that serial studies may be performed with safety. We believe serial studies are especially important in patients with a changing disease status such as occurs in pyelonephritis. With the need to keep radiation exposure at a minimum, the more rapidly excreted material is desirable. Those patients with moderate impairment of renal function may also be studied with safety and in some instances, renal scan may be the only possible visualizing technique aside from retrograde examination. Because of the problem in timing inherent in the choice of material, further refinement in technique by increasing the speed of

scanning is in progress. Ideally, with two scintillation counters mounted together, both kidneys can be scanned simultaneously, thereby reducing the time of scanning and the required amount of I-131 labeled material administered. SUMMARY

A method of obtaining renal scan patterns, and the correlating data have been presented in studies of patients with renal infection, neoplasm, and congenital anomaly. The authors express gratitude for assistance rendered by Dr. Mary C. Morgan and the staff of the Radioisotope Service.