Isotopes

Any given element may have many isotopes

All isotopes of a given element have the same no of protons and differ
only in the no of neutrons

Some of these isotopes have unstable nuclear configuration and seek

greater stability by decay/disintegration to a more stable form

Isotopes attempting to reach stability by emitting radiation are called

radionuclides/radioisotopes
 Radionuclides
• Photon Emitting(imaging)
• Tc99m
• Mo99
• I123
• Ga67
• In113
• Kr81
• Th201
• Positron Emitting(imaging)
• C11
• N13
• O15
• F18
• Rb82
• Used for therapy
• P32
• Sr89
• Y90
• I131
• Sm153
 Radionuclides for Imaging
Desirable characteristics
Minimum particulate emission

Primary photon energy between 50-500 KeV

Physical T1/2 > time required to prepare material

Effective T1/2 longer than examination time

Low toxicity

Stability or near stability of the product

 Technetium 99m

Fulfills many criteria of ideal radionuclide

No particulate emission

6 hour half life

A predominant (98%) 148KeV photon conversion

Used in > 70% of nuclear imaging procedures

• RADIOPHARMACEUTICALS = RADIONUCLIDES + PHARMACEUTICAL
 NUCLEAR SCINTIGRAPHY TECHNIQUES

1) 2D Scintigraphy
use of internal radionuclides to create two dimensional images

2) 3D SPECT
tomographic technique using gamma camera data from many projections and
reconstructed in different planes

3) HYBRID SCAN
SPECT/CT
PET/CT
 TOPICS

• Renal Scintigraphy

• ACEI Renal Scan

• Renal Transplant Scintigraphy

• Radionuclide Cystogram
 Renal Scintigraphy
INDICATIONS
1) Renal Perfusion and Function
2) Urinary Tract Obstruction (Furosemide Renal Scan)
3) Reno-Vascular HTN (Captopril Renal Scan)
4) Infection (Renal Morphology Scan)
5) Pre-Surgical Quantitation (Nephrectomy)
6) Renal Transplantation
7) Congenital Anomalies/Masses(Renal Morphology Scan)
 Radiopharmaceutical Agents
1) Those excreted by Glomerular Filtration (Glomerular Filtrating Agents)

1) Tc 99m-DTPA

2) Cr51-EDTA

3) I125-Iothalamate

2) Those excreted by Tubular Secretion (Tubular Secreting Agents)

1) I123/I131-OIH

2) Tc99m-MAG3

3) Tc99m-EC

3) Those retained in the Renal Tubules for long periods (Cortical Agents)

1) Tc99m-DMSA (Dimercaptosuccinic Acid)

2) Tc99m-GHA (Glucoheptonate)
99mTc-DTPA (Diethylenetriamine penta acetic acid)
99mTc-DTPA (Diethylenetriamine penta acetic acid)
• Inulin clearance remains the gold standard to measure GFR, but it is expensive, time consuming,
and requires a steady-state plasma concentration and accurate and timed urine collection

• Tc99m-DTPA is recommended agent for GFR measurement

• 5- 10% plasma protein binding, so it tends to underestimate the GFR (insignificant)

• Peak renal activity after 3 – 4 min

• 90 % filtered within 4 hours

• The extraction fraction of 99mTc -DTPA is approximately 20 per cent; for this reason, not useful for
imaging, in patients with impaired renal function

• In such cases, agents with higher extraction efficiencies such as 99mTc -MAG3 are more
appropriate
 51Cr-EDTA

May provide more accurate values for GFR

But cannot be used for imaging

 I-131/I-123 Orthoiodohippurate
• Para-aminohippuric acid (PAH) is the gold standard for the measurement of ERPF. However, it is not well
suited for routine studies

• I-131/I-123 Orthoiodohippurate has chemical structure similar to the Para-aminohippuric acid

• Tubular Secretion 80%

• Glomerular Filtration 20%

• Chemically & pharmacokinetically similar to PAH

• Plasma protein binding 70%

• Cortical peak time 3-5 min

• Radiation absorbed dose to bladder 0.74 rad/mCi

• The main disadvantages of 131I-OIH are the suboptimal imaging characteristics of 131I

• 123I-OIH has better imaging qualities, but 123I is more expensive and less available
 99mTc-MAG3 (Mercaptoacetyl triglycine)

• PROTEIN BINDING 70 – 90 %

• TUBULAR SECRETION 89%

• GLOMERULAR FILTRATION 11%

• Extraction fraction 40-50%

• Provides a high target-to-background ratio, good image quality, and

more accurate numerical values, particularly when the kidney
function is low or immature
 99mTc-EC (Ethylene dicysteine)
• 4 different forms
• D,D-EC

• L,L-EC

• D,L-EC

• L,D-EC

• EC is Metabolite of the L,L-ECD(ethylene cystine dimer) with cortical uptake

• Secretion in proximal convoluted tubules

• Plasma protein binding is 50%

• Exact excretion mechanism is not known

• Clearance is 69-85% of OIH

 99mTc-DMSA (Dimercaptosuccinic Acid)
• INDICATIONS: PYELONEPHRITIS, INFARCTS, SCARS, ANOMALIES

• 75% protein binding in 6 hrs

• 5- 20 % excretion 2 hrs

• 37% excretion in 24 hrs

• 40-50% cortical localization

• Maximum activity at 3-6 hrs

• 2 TO 5 mCi i.v

• Images at 2 – 4 hrs

• Importantly, acute infection can produce abnormalities in the scan

• If the test is being performed to evaluate for cortical scarring, it should be done at least 3 months after an acute infection
 99mTc-GHA (Glucoheptonate)

• It is both filtered by the glomerulus and bound by the tubules

• Glomerular filtration 80-90%

• Tubular secretion 10-20%

• 25-40% in 1 hr & 70% in 24 hrs in urine

• 15% bound to PCT

• EARLY DYNAMIC FUNCTIONAL imaging and DELAYED CORTICAL imaging

• 10-15 mCi
Renal Handling Radiopharmaceutical Imaging Clinical Use
No GFR
Glomerular Filtration Cr51-EDTA
Yes GFR
Tc 99m-DTPA
Yes ERPF
Tubular Secretion I123/I131-OIH
Yes ERPF
Tc99m-MAG3
Yes ERPF
Tc99m-EC
Yes Cortical Imaging
Tubular Retention Tc99m-DMSA
Yes Cortical Imaging
Tc99m-GHA
 Choosing Renal Radiotracers
Clinical Question Agent

Perfusion MAG3
DTPA
GHA
Morphology DMSA
GHA
Obstruction MAG3
DTPA
OIH
GFR quantitation I125-Iothalamate
Cr51-EDTA
DTPA
ERPF quantitation MAG3
OIH
 Basic Renal Scintigraphy

Patient Preparation

• Patient must be well hydrated

• Give 5-10 ml/kg water (2-4 cups) 30-60 min. pre-injection

• Can measure Urine specific gravity (<1.015)

• Void before injection

• Void at the end of study

 Basic Renal Scintigraphy
Acquisition

• Supine position is preferred

• Flow (angiogram): 2-3 sec / frame x 1 min

• Dynamic: 15-30 sec / frame x 20-30 min

• (Display @ 1-3 min/frame)

• Obtain a 30-60 sec. image over injection site at the end of study
• If infiltration >0.5% dose, do not report clearance

• Obtain post-void supine image of kidneys at the end of study

 International Consensus Committee
Recommendations for Basic Renogram
• Tracer
• MAG3
• DTPA

• Dose
• Adult 2 - 5 mCi
• Paeds Minimum 0.5 mCi

• Pt. position
• supine (motion, depth issues)
• Include bladder, heart

• Collimator
• LEAP

• Image over injection site

 Radionuclide Renal Evaluation
• Functional Imaging
• Visual assessment of perfusion and function

• Renography
• Time activity curve, representative of renal function

• Quantification of Renal Function

• GFR
• ERPF

• Anatomic Imaging
• cortical imaging
 Functional Imaging
• Perfusion Imaging • Renal Functional Imaging

• Evaluation of renal blood flow • At the end of perfusion sequence, imaging for function begins

• Native kidneys – posterior projection • Dynamic or sequential static; 3-5 min Tc99m DTPA or MAG3

• Transplanted kidneys – anterior projection are then obtained over 20-30 mins.

• 10-20mCi of radiopharmaceutical injected IV in antecubital • Evaluation is similar to an IVP with – anatomy, position,

vein symmetry and adequacy of function & collecting system

patency
• Imaging renal perfusion is usually begun as soon as bolus is

seen in abdominal Aorta • With Tc99m MAG3 maximal parenchymal activity is seen at 3-

5 min
• Subsequent images are taken every 1-5 secs
• Activity in collecting system and bladder by 4-8 mins
• In normal renal blood flow

• By 3 sec aorta is fully visualized

• By 5-6 sec, both kidneys are seen

• Maximal kidney activity is reached in 30-60 sec

 Renography

• A Time Activity Curve

• Graphic representation of uptake and excretion of

radiopharmaceutical

• Information is displayed from time of injection to about 20-30 mins

 Renogram Phases
• FLOW / VASCULAR PHASE
• Radionucletide angiogram

• Last for 30-60 sec

• Max activity 4-6 secs after peak aortic activity

• FUNCTIONAL PHASE (30 MIN )

• Parenchymal(Uptake) Phase
• Max activity 3 to 5 min

• Uptake at 2 to 3 min for split function

• Washout (Excretory) Phase

• no activity after 30 min
 Data obtained from Renogram
• Time to peak cortical activity
• 3-5 min

• Half-time excretion
• Time for half of peak activity to be cleared from kidney
• 8-12 mins

• Cortical activity at 20 min/ peak activity

• < 0.30 on MAG3 renogram
 RELATIVE/SPLIT FUNCTION
• Contribution of each kidney to the total renal function
Net cts in Lt ROI
• % Lt Kid = --------------------------------------- x 100%
Net cts Lt + net cts Rt ROI

• ROI: Region of interest

• Normal 50/50 - 56/44

• Borderline 57/43 - 59/41

• Abnormal > 60/40

 Quantitation of Renal Function
• GFR measurement

• ERPF measurement

• Two methods

• Plasma Sample Based Clearances

• The amount of activity remaining in blood at prefixed times is a measurement of activity not yet cleared
• indirect measure of activity already cleared
• More accurate ,but requires determination of pharmaceuticals levels in plasma and sometimes in urine

• Camera Based Clearances

• Counts are obtained from syringe before inj. & subsequently over kidneys after injection
• No blood and urine collection
• Sufficiently reliable method
 Anatomic (Cortical) Imaging
(Tc99m DMSA or GH)
• Images obtained after 2 to 4 hrs of injection

• Posterior/ right post. Oblique/ left post. Oblique

• NORMAL FINDINGS
• Smooth contour

• Homogeneous activity

• Less uptake in medulla

• No activity in PCS
 Diuretic (Furosemide) Renal Scan
• Obstructive uropathy (HDN, HDU) may lead to obstructive nephropathy
(loss of renal function)
• Indications
1) Evaluate functional significance of HDN
2) Determine need for surgery
1) Obstructive HDN - surgical Rx
2) Non-obstructive HDN - medical Rx/ follow up

3) Monitor effect of therapy

 Diuretic (Furosemide) Renal Scan

PRINCIPLE

• HDN - tracer pooling in dilated renal pelvis

• Furesemide induces increased urine flow

• If obstructed >>> will not wash out

• If dilated, non-obstructed >>> will wash out

• Can quantitate rate of washout (T1/2)

Diuretic (Furosemide) Renal Scan
 Diuretic (Furosemide) Renal Scan
PROTOCOL
• Oral hydration prior to study
• NS @ 15ml/kg over 30 min 15 min prior to injection & continued in study @ 200ml/kg/24 hr

• Bladder catheterization is required in children

• Tc 99m MAG3 – agent of choice in children with limited function

• High target-to-background ratio, good image quality, and more accurate numerical values

• Pre requisite – residual function to respond

• Diuretic given (infants- 1mg/kg, children 0.5 mg/kg, 40 mg adults ) 20-30 min after radiotracer injection

• Imaging for 20 – 30 minutes, post micturition image

• Functional images, renogram time/activity curve ( before & after ), wash out half time calculated

• Symmetric uptake and good washout is by definition not obstructed

 Washout (diuretic response)
T1/2
• Time required for 50% tracer to leave the dilated unit i.e. time
required for activity to fall to 50% of peak

• Normal < 10 min

• Indeterminate 10 - 20 min

• Obstructed > 20 min

 “F minus 15” Diuretic Renogram

• Furosemide (Lasix) injected 15 min before radiopharmaceutical

• Rationale: kidney in maximal diuresis, under maximal stress

• Some equivocals will become clearly positive, some clearly negative