Jnmt056622 162.168

Procedure Guideline for Diuretic Renographyin Children 3.0* Barry L. Shulkin1, Gerald A. Mandell2, Jeffrey A. Cooper3, Joe C. Leonard4, Massoud Majd5, Marguerite T. Parisi6,George N. Sfakianakis7, Helena R. Balon8, and Kevin J. Donohoe9 1St. Jude Children’s Research Hospital, Memphis, Tennessee; 2Phoenix Children’s Hospital, Phoenix, Arizona; 3Albany Medical Center,Albany, New York; 4Oklahoma Children’s Memorial Hospital, Oklahoma City, Oklahoma; 5Children’s National Medical Center,Washington, DC; 6Children’s Hospital and Regional Medical Center, Seattle, Washington; 7University of Miami School of Medicine,Miami, Florida; 8William Beaumont Hospital, Royal Oak, Michigan; and 9Beth Israel Deaconess Medical Center, Boston,Massachusetts infused with increasing amounts of fluid, is relatively inva- The purpose of this guideline is to assist nuclear medi- sive. It may overestimate obstructive phenomena and diag- cine practitioners in recommending, performing, inter- nose obstruction in cases of reduced renal function, when preting, and reporting the results of diuretic renography in obstruction appears to occur at a flow rate that the kidney with Diuretic renography is a safe and valuable method for the evaluation of renal function and differentiation between II. BACKGROUND INFORMATION AND DEFINITIONS obstructive and nonobstructive causes of renal or ureteral Pelvicaliectasis (distension of the pelvicalyceal system) with or without megaureter (distension of the ureter) is the Hydronephrosis detected in utero may resolve spontane- most common indication for radionuclide evaluation of the ously and is related to physiologic change during early kidneys in pediatric patients. Pelvicaliectasis may result development. The diagnosis of obstruction often requires from either congenital or acquired etiologies. Included sequential scintigraphic examinations.
among the causes of pelvicaliectasis are entities such as Injection time for furosemide in relation to tracer injec- an obstructed renal pelvis, an obstructed ureter, a duplex tion is indicated by the letter ‘‘F.’’ As an example, injection renal collecting system, vesicoureteral reflux, bladder ab- of furosemide 20 min after tracer injection is indicated as normalities including neurogenic bladder, bladder outlet obstruction, and infection. Pelvicaliectasis and megauretercan result from obstructive or nonobstructive causes. Ob-struction may occur at the level of the ureteropelvic junc- tion, the ureterovesical junction, the posterior/prostatic urethra, or uncommonly in the ureter. Nonobstructive causes 1. Preparation before arrival in the department is usually include vesicoureteral reflux, nonobstructive pelvicaliectasis not necessary. If the patient is not going to receive or megaureter, prune belly syndrome, and congenital mega- intravenous fluids, oral hydration is encouraged be- fore arrival and while in the department. Oral fluids in Contrast intravenous urography, ultrasonography, and the range recommended for intravenous administra- conventional radionuclide renography cannot reliably dif- tion are appropriate (see III A.2.e.).
ferentiate obstructive from nonobstructive causes of pelvi- 2. Preparation before injection of the radiopharma- The pressure perfusion study (Whitaker test), which mea- a. The procedure is explained to parents and all sures collecting system pressure while the renal pelvis is children old enough to understand. Parents can re-main and help with the examination if their pres-ence is beneficial.
Received Aug. 4, 2008; revision accepted Aug. 4, 2008.
For correspondence or reprints contact: Kevin Donohoe, Beth Israel b. Continual communication and reassurance with Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215.
explanation of each step is essential for coopera- E-mail: [email protected]*YOU CAN ACCESS THIS ACTIVITY THROUGH THE SNM WEB SITE tion and successful intravenous injection of the radiopharmaceutical and catheterization of the COPYRIGHT Ó 2008 by the Society of Nuclear Medicine, Inc.
DOI: 10.2967/jnmt.108.056622 JOURNAL OF NUCLEAR MEDICINE TECHNOLOGY • Vol. 36 • No. 3 • September 2008 c. Oral hydration (volume expansion) may be suffi- g. Some laboratories do not use intravenous hydra- cient in certain situations. Intravenous hydration is tion or catheter bladder drainage for the initial more reliable in the diagnosis of questionable cases evaluation (particularly in older children) so that of urinary obstruction. An indwelling venous cath- kidneys can be evaluated without intervention.
eter may be inserted to maintain sufficient hydra-tion for a good diuretic effect and obviate repeated B. Information Pertinent to Performing the Procedure traumas from multiple percutaneous injections. For 1. Awareness of a prenatal history of urinary tract di- the administration of the diuretic at the time of lation, a history of prior surgery to the urinary tract, tracer injection (F0), a 21- or 23-gauge butterfly and congenital urinary abnormalities (duplex systems, needle is used for the simultaneous injection of the renal fusion, etc.) are important for accurate interpre- radiopharmaceutical and the diuretic and may be 2. The review of available past radiographic, ultrasound, d. Bladder catheterization is not always necessary and radionuclide studies adds to the accuracy of but is suggested if it is necessary to evaluate interpretation of the current study.
patients with bladder pathology or in questionable 3. Nonlatex materials should be used in patients prone cases; it is also sometimes necessary to catheterize to latex allergy (e.g., patients with congenital spinal the patient after the study, to evaluate the effect of defects and chronic urethral catheterization).
the urinary bladder. In some cases, the diagnosis 4. An allergy to sulfa drugs may prevent the use of of obstruction may be more reliable with bladder furosemide (cross reactivity between sulfa and fu- or pelvic drainage catheterization. Older children rosemide) in a small percentage of patients. Urethral who are not catheterized are requested to void anesthesia with lidocaine should not be used in patients with an allergic history to lidocaine or itsderivatives.
i. Sterile urethral catheterization should be per- formed with the largest-sized Foley or feeding catheter that will comfortably pass the meatus 1. The examination table is covered with plastic-lined (a 2.6-mm-diameter catheter [French 8] for absorbent paper to contain spilled tracer and reduce most patients and 1.8-mm-diameter [French 6] contamination of the table during drainage and cath- for infants). A French 8 feeding catheter 2. Gentle catheterization by a qualified individual can prevent an overly traumatic and painful experience ii. Continual drainage by catheterization of and results in better cooperation during follow-up the bladder may be required in patients with hydroureter, vesicoureteral reflux, a neuro- 3. Slow, deep breathing and a gentle forward motion of pathic bladder, a small-capacity bladder, a the catheter should be used to relax a spastic external dysfunctional bladder, or posterior urethral 4. An application of urethral anesthesia (3–5 mL of iii. The diuretic effect can be assessed by com- lidocaine jelly) in the male urethra 2–5 min before paring the volume of urine excreted during the catheterization helps decrease discomfort.
dynamic phase with the volume of urine ex- 5. A Foley balloon is inflated only after the catheter and its balloon are confirmed to be in the bladder. Urine return e. Hydration or volume expansion, in patients for can be appreciated with the balloon still positioned in whom there is no cardiovascular contraindication, the posterior urethra. The balloon must be deflated is suggested to reduce the incidence of false- before removal from the bladder. When a feeding tube positive findings. Ten to 15 mL/kg of one third is used for bladder drainage, it should not be advanced or greater normal saline (with or without 5% too far, to avoid coiling and knot formation.
dextrose) for 30 min are infused before the di- 6. Caution should be observed with postural changes uretic is administered. The slow administration of because of possible diuresis-induced hypotension.
fluid is continued during the remainder of the 7. Sudden abdominal or flank pain can arise during acute distension of the pelvicalyceal system in some patients.
f. If the rate of urine flow is low during hydration, a 8. There is a small risk of catheter-induced trauma and larger amount of fluid (up to 40 mL/kg) can be administered cautiously with careful assessmentof volume status (with particular attention to patients who may have renal or cardiac compro- 1. The preferred radiotracer, 99mTc-mercaptoacetyltri- glycine (99mTc-MAG3), is cleared mainly by tubular DIURETIC RENOGRAPHY IN CHILDREN • Shulkin et al.
secretion. After about 3 h, 90% of the injected dose static images before and after the patient is kept upright can be recovered in the urine. 99mTc-MAG3 has a high initial renal uptake, providing high kidney-to-backgroundratios with good temporal resolution. 99mTc-MAG3 is recommended for neonatal renography and for visu- 1. The dose of furosemide (Lasix; Sanofi-Aventis) is alization of kidneys in patients with compromised 1.0 mg/kg, with a usual maximum dose of 40 mg. A renal function. The recommended administered dose higher diuretic dose may be necessary in cases of is 1.9 MBq (50 mCi) per kilogram of body weight obesity, chronic use of diuretics, or impaired renal (minimum, 19 MBq [0.5 mCi]). Some laboratories use function, either unilateral or bilateral.
2. There are 3 different approaches for the time of injec- 2. 99mTc-diethylene triamine pentaacetic acid (99mTc- tion of the diuretic furosemide (F).
DTPA) is a glomerular agent. The biologic half-life is a. In the method endorsed by the American Society less than 2.5 h, and 95% of the administered dose is of Fetal Urology, the diuretic is injected at 20 min cleared by 24 h. The recommended administered dose or later after the radiopharmaceutical (F 1 20 or is 3.7 MBq (100 mCi) per kilogram of body weight later), when the entire dilated system is filled with Radiation dose estimates are shown in Tables 1 and 2.
b. In the method developed in Europe, the diuretic is injected 15 min before the injection of the radio- 1. The study is a dynamic renal scan with the patient supine c. In the F 2 0 method, used by some laboratories in and with the patient’s back to the camera. Serial 15- to the United States and Australia, there is simulta- 30-s images (64 · 64 or 128 · 128 matrix) are acquired neous injection of the radiopharmaceutical and the for 30–60 min, depending on the technique chosen.
2. A 1-min flow study may be acquired, but the data from the flow should be incorporated into the function study mentioned above. Grouping the data into 2-min 1. From the dynamic renal study, careful evaluation of the images simplifies the visual interpretation.
parenchymal phase reveals renal function, size, and 3. For F 1 20 or later technique, the prediuretic and position. Cortical transit time and dilatation of the postdiuretic phases are acquired either as a single collecting system may be examined in the excretory dynamic study starting immediately after the injection of the radiopharmaceutical and continued for 20–30 2. Baseline images of the diuretic phase are used for min after the injection of furosemide or as 2 separate 3. Cinematic viewing of the diuretic phase assesses pa- 4. For F 2 15 and F 2 0 techniques, dynamic images are tient movement. If there is considerable patient mo- acquired for 20–30 min after injection of the radio- tion, regions of interest around the collecting systems of individual frames will have to be compared at 5. If postdiuresis clearance with the patient supine is poor, various intervals of the study to assess drainage.
additional dynamic images with the patient prone may 4. Regions of interest are drawn around the dilated be obtained. An alternative technique is acquisition of pelvicalyceal system for curve analysis and calcula- Estimated radiation dose equivalent (mSv/MBq) 1Stabin and Gelfand. Q J Nucl Med. 1998;42:93–112.
JOURNAL OF NUCLEAR MEDICINE TECHNOLOGY • Vol. 36 • No. 3 • September 2008 Radiation Dose Estimates for 99mTc-DTPA Injection1 Estimated radiation dose equivalent (mSv/MBq) 1Stabin and Gelfand. Q J Nucl Med. 1998;42:93–112.
tion of the half-time (T1/2). One to 2 background 4. With the injection of the diuretic after the radiophar- regions can also be drawn. The reader is referred to a maceutical (F 1 20 or later), a T1/2 less than 10 min standardized technique of the ‘‘well-tempered’’ diu- usually means the absence of obstruction, and a T1/2 retic renogram and recommendations by international greater than 20 min usually identifies obstruction. A T1/2 with a value between 10 and 20 min is an 5. The diuretic T1/2 is the time at which the time–activity equivocal result. These T1/2 measurements are appli- curve decreases to half its maximal activity. A re- cable to neonatal hydronephrosis. The natural history search study applying F 2 15, F0, and F 1 20 of neonatal hydronephrosis is variable. Drainage may indicated that the 3 methods are equivalent for indi- gradually improve or worsen. Therefore, follow-up cating obstruction. They differ in duration (shorter F0) examinations are usually necessary. These T1/2 values and in patient acceptance and cost (F0 favored). F0 refer to kidneys with normal or near-normal function.
and F 2 15 also allow evaluation of the renal pa- Kidneys with reduced function may have prolonged renchyma in nonobstructed cases and contribute to the work-up of parenchymal disorders such as focal acute 5. With the injection of the diuretic before the radio- pyelonephritis, HIV nephropathy (AIDS nephropa- pharmaceutical (F 2 15), a T1/2 greater than 20 min is 6. For F 1 20 studies, residual activity can be reported 6. With the simultaneous injection of the radiopharma- by estimating the percentage of tracer activity that ceutical and furosemide (F0), a T1/2 greater than 20 min remains at 20 min after injection of the diuretic, is compatible with obstruction. In cases, however, of compared with the activity at the time of diuretic extrarenal pelvis, nonobstructing pelviectasis and injection. Individual curves from the renal cortices megaureters of long standing, and particularly post- should be produced by carefully assigning the renal operative patients with residual dilatation of the cortex away from the collecting system. Such curves collecting system, the possibility of obstruction is can be useful in cases of extrarenal pelvis, non- studied mainly by observing the cortex and the cor- obstructing pelviectasis, and megaureter and espe- tical graphs. When the cortical graphs are normal and cially in postoperative cases with residual dilatation of the cortices appear empty, then there is no obstruc- the collecting system but no obstruction.
tion, even if the curves of the total kidneys have a T1/2greater than 20 min. The F0 study should therefore beinterpreted not only for the behavior of the collecting system but also for the behavior of the cortex of the 1. The diuretic effect usually begins within 1–2 min after The neonatal kidney is functionally immature. As a 2. In the absence of obstruction, rapid and almost result, in the F0 study, neonatal kidneys may show complete washout of the radiotracer occurs before increased residual cortical activity, retaining up to injection of diuretic. However, if function is de- 50% or more of the peak because of immaturity of the creased, there may be slow emptying of the kidneys.
kidneys. Such a phenomenon disappears after the age 3. Obstructed systems can result in delayed drainage from the collecting system. The amount of activity This method (F0) applied in the neonate with a proximal to the obstruction can also increase over dilated collecting system has been observed to provide definitive indications for the existence of obstruction if DIURETIC RENOGRAPHY IN CHILDREN • Shulkin et al.
the renogram of the entire kidney is upsloping contin- 4. Poor renal function from prolonged severe obstruction uously. Such patients often require surgery. Patients can result in slow tracer accumulation in the dilated with a downsloping curve usually compensate and collecting system and result in difficulty in interpreta- do not need an immediate operation, but follow-up.
tion of the diuretic phase. The F0 study provides Patients with a horizontal graph need close observation additional help by indicating a normal emptying cortex because some of them require surgery.
in cases of no obstruction. In cases of obstruction, the In acquired obstruction (tumors, renal stones, etc.) cortex shows prolonged retention of the activity.
complete obstruction is characterized by nonvisuali- 5. A large, unobstructed collecting system with rela- zation of the collecting system, associated with a tively good renal function can exhibit slow drainage rising curve from the parenchyma; blood flow is often of the radiotracer (prolonged T1/2). The F0 method decreased. Partial obstruction is characterized by indicates normal emptying of the cortex.
delayed and persistent visualization of the drainage 6. When the obstruction is at both the pelvicalyceal and system and cortical retention of the activity, associ- the ureterovesical junctions, detection of the uretero- ated with decreased blood flow. The acute postob- vesical junction obstruction may be difficult.
struction/postdecompression image (stunned kidney) 7. Patient movement may invalidate curve analysis.
shows cortical retention, relatively better flow, faint (if 8. Urinary systems considered normal in the prediuretic any) visualization of the intrarenal collecting system, phase may not be evaluated for postdiuresis drainage.
but always visualization of the ureter (may need A prolonged T1/2 can be obtained because of the relatively small amount of residual activity in the col- 7. The shape of the resulting time–activity curves of the lecting system to respond to the diuretic challenge.
washout study has been used for differentiation of With the F0 approach, in rare cases the use of the stasis from obstruction. Lack of radiotracer decline diuretic has uncovered borderline obstructions asso- after furosemide suggests obstruction, although this ciated with normal baseline studies in symptomatic can be mimicked by impaired renal function. A brisk patients (pain after much drinking).
decline in activity after diuretic is consistent withstasis without obstruction.
IV. ISSUES REQUIRING FURTHER CLARIFICATION A. The calculation method of the postdiuresis drainage 1. The procedure, date of the study, activity and route of is variable, but a standardized technique is available administration of the radiopharmaceutical, and a pre- vious study for comparison are included.
B. The curve analysis has been questioned because of 2. The history includes symptoms or diagnosis.
poor correlation with pressure perfusion studies in 3. The technique includes catheter size and type if implemented, amount and kind of intravenous fluid C. The results of the alternative method of simultaneous if administered, the imaging sequence, the amount injection of the radiopharmaceutical and diuretic and time of diuretic administration, and the urine remain to be validated. However, in some laboratories volumes before and after the diuretic, if measured.
the method provides valuable and accurate diag- 4. The findings may include renal perfusion, split renal nostic and prognostic information noninvasively and function, transit times, and the T1/2 of collecting There are no issues of quality control.
A. Bird VG, Gomez-Marin O, Leveillee RJ, Sfakianakis GN, Rivas LA, Amendola MA. A comparison of 1. Infiltration of the radiopharmaceutical or diuretic may unenhanced helical computerized tomography find- ings and renal obstruction determined by furosemide 2. Insufficient hydration can result in delayed uptake and 99m-technetium mercaptoacetyl-triglycine diuretic excretion, simulating poor function, or can demon- scintirenography for patients with acute renal colic.
strate a normal response in the presence of significant B. Conway JJ. Radionuclide cystography. In: Tauxe 3. If the diuretic is administered before the maximum WN, Dubovsky EV, eds. Nuclear Medicine in Clin- distension of the collecting system, the response may ical Urology and Nephrology. East Norwalk, CT: not reflect the true physiologic state. However, in the Appleton, Century and Crofts; 1985:305–320.
F0 method, the cortex empties appropriately, and this C. Conway JJ. ‘‘Well-tempered’’ diuresis renography: its observation compensates for this phenomenon.
historical development, physiological and technical JOURNAL OF NUCLEAR MEDICINE TECHNOLOGY • Vol. 36 • No. 3 • September 2008 pitfalls, and standardized technique protocol. Semin R. Sfakianakis GN, Carmona AJ, Sharma A, et al.
Diuretic MAG3 scintirenography in children with D. Donoso G, Kuyvenhoven JD, Ham H, Piepsz A.
HIV nephropathy: diffuse parenchymal dysfunction.
99mTc-MAG3 diuretic renography in children: a com- parison between F0 and F120. Nucl Med Commun.
S. Sfakianakis GN, Sfakianakis E. Renal scintigraphy in infants and children. Urology. 2001;57:1167– E. Eskild-Jensen A, Gordon I, Piepsz A, Frokiaer J.
Congenital unilateral hydronephrosis: a review of the T. Sfakianakis GN, Vensel EE, Tapia-Palacios M, et al.
impact of diuretic renography on clinical treatment.
The value of MAG3-Fo diuretic renography in predicting the need for surgery in the neonate with F. Foda MM, Garfield CT, Matzinger M, et al. A uretero-pelvic junction obstruction [abstract]. J Nucl prospective randomized trial comparing 2 diuresis renography techniques for evaluation of suspected U. Shokeir AA, El-Sherbiny MT, Gad HM, et al. Post- upper urinary tract obstruction in children. J Urol.
natal unilateral pelviureteral junction obstruction: impact of pyeloplasty and conservative management G. Houle AM, Cheikhelard A, Barrieras D, Rivest MC, on renal function. Urology. 2005;65:980–985.
Gaudreault V. Impact of early screening for reflux in V. Stabin MG, Gelfand MJ. Dosimetry of pediatric nuclear siblings on the detection of renal damage. Br J Urol medicine procedures. Q J Nucl Med. 1998;42:93–112.
W. Vlajkovic M, Ilic S, Rajic M, Petronijevic V, Bubanj T, H. Jung HS, Chung YA, Kim EN, et al. Influence of Artiko V. Diuresis renal scintigraphy ‘‘F20’’ in di- hydration status in normal subjects: fractional analy- agnosing of upper urinary tract obstruction in chil- sis of parameters of Tc-99m DTPA and Tc-99m dren: the clinical significance. Nucl Med Rev. 2005:8: MAG3 renography. Ann Nucl Med. 2005;19:1–7.
I. Kass EJ, Majd M. Evaluation and management of the X. Wackman J, Brewer E, Gelfand MJ, et al. Low grade upper urinary tract obstruction in infancy and child pelviureteric obstruction with normal diuretic renog- hood. Urol Clin North Am. 1985;12:122–141.
raphy. Br J Urol. 1986;58:364–367.
J. Kuyvenhoven JD, Ham HR, Piepsz A. The estimation Y. Whitaker RH, Buxton TMS. A comparison of pres- of renal transit using renography: our opinion. Nucl sure flow studies and renography in equivocal upper tract obstruction. J Urol. 1986;131:446–449.
K. Liu Y, Ghesani NV, Skurnick JH, Zuckier LS. The F 1 0 protocol for diuretic renography results infewer interrupted studies due to voiding than the F 2 15 protocol. J Nucl Med. 2005;46:1317–1320.
The SNM has written and approved this Procedure Guide- L. Meller ST, Eckstein HB. Renal scintigraphy: quanti- line as an educational tool designed to promote the cost- tative assessment of upper urinary tract dilatation in effective use of high-quality nuclear medicine procedures in children. J Pediatr Surg. 1981;16:123–126.
medical practice or in the conduct of research and to assist M. Piepsz A, Ham HR. Pediatric applications of renal practitioners in providing appropriate care for patients. The nuclear medicine. Semin Nucl Med. 2006;36:16–35.
Procedure Guideline should not be deemed inclusive of all N. Piepsz A, Ismaili K, Hall M, Collier F, Tondeur M, proper procedures or exclusive of other procedures reason- Ham H. How to interpret a deterioration of split ably directed to obtaining the same results. The guidelines function. Eur Urol. 2005;47:686–690.
are neither inflexible rules nor requirements of practice and O. Prigent A, Cosgriff P, Gates GF, et al. Consensus are not intended nor should they be used to establish a legal report on quality control of quantitative measure- standard of care. For these reasons, the SNM cautions ments of renal function obtained from the renogram: against the use of this Procedure Guideline in litigation in International Consensus Committee from the Scien- which the clinical decisions of a practitioner are called into tific Committee of Radionuclides in Nephrourology.
The ultimate judgment about the propriety of any spe- P. Senac MO, Miller JH, Stanley P. Evaluation of cific procedure or course of action must be made by the obstructive uropathy in children: radionuclide re- physician when considering the circumstances presented.
nography versus the Whitaker test. AJR. 1984;143: Therefore, an approach that differs from the Procedure Guideline is not necessarily below the standard of care. A Q. Sfakianaki E, Panagakos GM, Rodriquez JA, Georgiou conscientious practitioner may responsibly adopt a course MF, Leveilee RJ, Sfakianakis GN. Evaluation of of action different from that set forth in the Procedure obstruction in patients with extrarenal pelvis using Guideline when, in his or her reasonable judgment, that time zero diuretic renography [abstract]. J Nucl Med.
course of action is indicated by the condition of the patient, limitations on available resources, or advances in knowl- DIURETIC RENOGRAPHY IN CHILDREN • Shulkin et al.
edge or technology subsequent to publication of the Pro- Advances in medicine occur at a rapid rate. The date of a Procedure Guideline should always be considered in deter- All that should be expected is that the practitioner will follow a reasonable course of action based on currentknowledge, available resources, and the needs of the patientto deliver effective and safe medical care. The sole purpose of this Procedure Guideline is to assist practitioners in achiev- This Procedure Guideline was approved by the Board of Directors of the SNM on April 15, 2007.
JOURNAL OF NUCLEAR MEDICINE TECHNOLOGY • Vol. 36 • No. 3 • September 2008

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