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PAEDIATRIC RENAL
IMAGING
Dr A Brink
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Causes of hydronephrosis includes:
Pelvi-ureteric obstruction
Vesico-ureteric reflux
Vesico-ureteric obstruction
Posterior uretral valves
Duplex kidneys
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Radiopharmaceutical of choice:
99m Tc-MAG3 (mercaptoacetyl triglycine):
Taken up in the kidney via tubular secretion (98%)
and glomerular filtration (2%).
90% protein bound.
40 % of MAG3 in blood is taken up into the
kidneys every time the blood circulates through the
kidneys.
70% of the MAG3 is in the urine 30 minutes after
injection.
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What do you need to get a good
quality MAG 3 scan ?
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What do you need to get a good
quality MAG 3 scan ?
A WORKING KIDNEY! Difficult and sometimes
impossible to interpret if there is CRF.
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MAG3 renogram = Dynamic study
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What is the most important information
supplied by the MAG3 renogram?
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What is the most important information
supplied by the MAG3 renogram?
The differential renal function.
The differential renal function.
The differential renal function.
The differential renal function.
The differential renal function.
The differential renal function.
The differential renal function.
The differential renal function.
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What is the most important information
supplied by the MAG3 renogram?
Differential renal function only tells us how the
kidneys work in relation with each other. It does not
give us information on the global renal function.
If you want to calculate the absolute differential
renal function, adding a GFR is imperative.
Absolute GFR is valuable in cases with bilateral
disease.
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How is Differential Renal Function (DRF)
calculated?
MAG3 cannot move through the nephron in under
2,5 minutes.
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How is Differential Renal Function (DRF)
calculated?
MAG3 cannot move through the nephron in under
2,5 minutes.
DRF is calculated on the 1-2 minute image. Given
adequate time for mixing and uptake. None of the
counts (radioactivity) can be in the collecting system
jet.
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How is DRF calculated?
Two accepted methods, Integral method and
Rutland Patlak plot.
Basic principle:
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How is DRF calculated:
We draw regions of interest (ROI) to tell the
computer where the kidneys are.
These are not allowed to cut the kidneys.
Backgound ROI’s – More than one method, C-
shaped and peri-renal most acceptable.
Background ROI’s Must stay inside the patient!
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So what does DRF measure?
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So what does DRF measure?
We are comparing the two kidneys with each other.
Normal range is:45-55%
It does not give an indication of how well the
kidneys work as a unit. You can have 50/50% DRF
and renal failure.
Problematic if there is bilateral disease, then it is
useful to add a validated GFR measurement to
calculate absolute DRF.
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The “Stages” of the renogram
Four “stages”:
Perfusion
Uptake
Excretion
Clearance
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The curve
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The curve
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“Lasix response”
Lasix response = Non – obstructed system
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The hydronephrosis dilemma
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Causes of absent lasix response
Dehydration
Large collecting system
Full bladder
Renal insufficiency
Renal immaturity
Inadequate diuretic dose
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Indications for Intervention
1. Infections/Complications.
2. Fall in differential renal function.
3. Increasing AP pelvis (relative indication).
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Background
Prenatal hydronephrosis is found in approximately
0.25% of pregnancies(1).
There is spontaneous resolution in:
50% of cases with mild
15% with moderate and
0% with severe hydronephrosis(2).
1.Helin I, Person P.H. Prenatal diagnosis of urinary tract abnormalities by ultrasound.
Pediatrics, 78:879, 1986.
2.Feldman, D.M. et al: Evaluation and follow-up of fetal hydronephrosis. J
Ultrasound Med, 20: 1065,2001.
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DRF 50/50%.
AP pelvis Calyceal
dilatation
Baseline
MAG3 at
Follow-up
MAG3 at
< 20 mm Seldom
marked
3/12 9/12
20 – 30mm Not marked 9/52 6/12 - 9/12
20 – 30mm Marked 6/52 3/12 – 6/12
30 - 40mm Not marked 6/52 6/52 – 3/12
30 – 40mm Marked 3/52 3/52 - 6/52
> 40 mm uncommon at 50/50% DRF
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IMAGING IN HYDRONEPHROSIS
Ultrasound studies are booked between two MAG3
studies. If the ultrasound results are of concern the
MAG3 study is moved forward.
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DRF 30/70%
DRF 30/70% follow-up MAG3 and ultrasound
studies are done earlier because the one kidney is
already compromised
As with DRF 50/50% the MAG3 renogram is moved
forward if the ultrasound results are of concern .
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DRF 15/85% - 20/80%
The follow-up MAG3 is done 2/52 - 4/52 after
initial study.
Consider doing a MCUG here.
These patients are candidates for
nephrostomy
early surgery
early stent.
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DRF of affected kidney < 10%.
Probably not salvageable, surgery often technically
very difficult.
Probably not worth saving.
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Reproducibility:
0
2
4
6
8
10
12
14
0 10 20 30 40 50 60 70 80 90 100
PI
SI
SRP
HI
HRP
II
IRP
Percentile
Sta
nd
ard
devia
tion
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Watch out if...
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Vesico-ureteric reflux
06-07-2010 18-01-2011
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VUR case study pt PG
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VUR case study Pt PG
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VUR case study Pt PG: indirect cystogram
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Bilateral hydronephrosis
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F A 40070567 10 June 2008 1-2
minute image
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F A 40070567 10 June 2008
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Fazili A 10 June 2008
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F A 40070567 10 June 2008