Disorders of Renal Function and Edemas

Renal Renal ScintigraphyScintigraphy

Helena Balon, MDHelena Balon, MDWm. Beaumont HospitalWm. Beaumont Hospital

Royal Oak, MichiganRoyal Oak, MichiganCharles UniversityCharles University

3rd School of Medicine3rd School of Medicine

Dept Nucl Med, PragueDept Nucl Med, Prague

Materials for medical studentsMaterials for medical students

IndicationsIndications

Renal perfusion and functionRenal perfusion and function Obstruction (Lasix renal scan)Obstruction (Lasix renal scan) Renovascular HTN (Captopril renal scan)Renovascular HTN (Captopril renal scan) Infection (renal morphology scan)Infection (renal morphology scan) Pre-surgical quantitation (nephrectomy) Pre-surgical quantitation (nephrectomy) Renal transplantRenal transplant Congenital anomalies, masses Congenital anomalies, masses

(renal morphology scan)(renal morphology scan)

Evaluation of:

Renal FunctionRenal Function

Blood flowBlood flow - 20% cardiac output to kidneys - 20% cardiac output to kidneys (1200 ml/min blood, 600 ml/min plasma)(1200 ml/min blood, 600 ml/min plasma)

FiltrationFiltration - 20% renal plasma flow filtered by - 20% renal plasma flow filtered by glomeruli glomeruli (120 ml/min, 170 L/d)(120 ml/min, 170 L/d)

Tubular secretionTubular secretion Tubular reabsorptionTubular reabsorption (1% ultrafiltrate - urine) (1% ultrafiltrate - urine) EndocrineEndocrine functions functions

Renal RadiotracersRenal Radiotracers

Excretion MechanismsExcretion Mechanisms

GF TS TFTc-99m DTPA >95%Tc-99m MAG3 <5% 95%I-131 OIH 20% 80%Tc-99m GHA 40%-60% 20%Tc-99m DMSA some 60%

Semin NM Apr.92

Renal Renal RadiopharmaceuticalsRadiopharmaceuticals

Extract. fraction Clearance

Tc-99m DTPA 20% 100-120 ml/min Tc-99m MAG3 40-50% ~ 300 ml/min I-131 OIH ~100% 500-600 ml/min

Renal RadiopharmaceuticalsRenal Radiopharmaceuticals

DosimetryDosimetry

DTPA MAG3 GHA DMSA DTPA MAG3 GHA DMSA I-I-

131131OIH OIH rad/10 mCirad/10 mCi rad/5mCi rad/5mCi rad/300µCirad/300µCi

KidneyKidney 0.2 0.2 0.15 0.15 1.61.6 3.5 3.5 0.010.01

BladderBladder2.82.8 5.1 5.1 2.72.7 0.3 0.3 0.30.3

EDE EDE (rem)(rem) 0.30.3 0.4 0.4 0.40.4 0.3 0.3 0.030.03

Choosing Renal Choosing Renal RadiotracersRadiotracers

PerfusionPerfusion MAG3, DTPA, GHAMAG3, DTPA, GHA

MorphologyMorphology DMSA, GHADMSA, GHA

Obstruction Obstruction MAG3, DTPA, OIHMAG3, DTPA, OIH

Relative functionRelative function AllAll

GFR quantitationGFR quantitation I-125 iothalamate, I-125 iothalamate,

Cr-51 EDTA, DTPACr-51 EDTA, DTPA

ERPF quantitationERPF quantitation MAG3, OIHMAG3, OIH

Clin. Question Agent

Basic Renal ScanBasic Renal Scan

ProcedureProcedure

Basic Renal ScintigraphyBasic Renal Scintigraphy

PatientPatient PreparationPreparation

Patient must be well hydratedPatient must be well hydratedGive 5-10 ml/kg water (2-4 cups) Give 5-10 ml/kg water (2-4 cups)

30-60 min. pre-injection30-60 min. pre-injectionCan measure U - specific gravity (<1.015)Can measure U - specific gravity (<1.015)

Void before injectionVoid before injection Void @ end of studyVoid @ end of study

Int’l Consens. Comm.Int’l Consens. Comm.Semin NM ‘99:146-159Semin NM ‘99:146-159

Basic Renal ScintigraphyBasic Renal Scintigraphy AcquisitionAcquisition

Supine position preferredSupine position preferred Do not inject by straight stickDo not inject by straight stick Flow (angiogram) : 2-3 sec / fr x 1 minFlow (angiogram) : 2-3 sec / fr x 1 min Dynamic: 15-30 sec / frame x 20-30 minDynamic: 15-30 sec / frame x 20-30 min

(display @ 1-3 min/frame)(display @ 1-3 min/frame)

Basic Renal ScintigraphyBasic Renal Scintigraphy Acquisition Acquisition (cont’d)(cont’d)

Obtain a 30-60 sec. image over injection site Obtain a 30-60 sec. image over injection site @ end of study @ end of study if infiltration >0.5% dose if infiltration >0.5% dose do not report do not report

clearanceclearance

Obtain post-void supine image of kidneys Obtain post-void supine image of kidneys @ end of study@ end of study

Taylor, SeminNM 4/99:102-127

International Consensus International Consensus Committee Recommendations for Committee Recommendations for

Basic RenogramBasic Renogram

Tracer: MAG3, (DTPA)Tracer: MAG3, (DTPA) Dose: 2 - 5 mCi adult, minimum 0.5 mCi pedsDose: 2 - 5 mCi adult, minimum 0.5 mCi peds

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

Collimator: LEAPCollimator: LEAP

Image over injection siteImage over injection siteInt’l Consens. Comm.Int’l Consens. Comm.Semin NM ‘99:146-159Semin NM ‘99:146-159

DTPA normalDTPA normal

DTPA normalDTPA normal

Relative (split) functionRelative (split) functionROI’sROI’s

Relative uptakeRelative uptake

Contribution of each kidney to the total fctContribution of each kidney to the total fct

net cts in Lt ROInet cts in Lt ROI

% Lt kid% Lt kid = --------------------------------------- x 100% = --------------------------------------- x 100% net cts Lt + net cts Rt ROInet cts Lt + net cts Rt ROI

NormalNormal 50/50 - 56/4450/50 - 56/44BorderlineBorderline 57/43 - 59/4157/43 - 59/41AbnormalAbnormal > 60/40> 60/40

Taylor, SeminNM Apr 99

Basic Renal ScintigraphyBasic Renal Scintigraphy ProcessingProcessing

Time to peakTime to peakBest from cortical ROIBest from cortical ROINormal < 5 minNormal < 5 min

Residual Cortical Activity (RCAResidual Cortical Activity (RCA20 or 3020 or 30))Ratio of cts @ 20 or 30 min / peak ctsRatio of cts @ 20 or 30 min / peak ctsUse cortical ROIUse cortical ROINormal RCANormal RCA2020 for MAG3 < 0.3 for MAG3 < 0.3

Residual Urine VolumeResidual Urine Volume (post-void cts x void. vol) (post-void cts x void. vol) (pre-void cts - post void cts) (pre-void cts - post void cts)

DTPA flow + scanDTPA flow + scan

GFR = 29 ml/’Creat = 2.0L= 33%R= 67%

Renal artery occlusionRenal artery occlusion

Rt renal infarctRt renal infarct

Renogram PhasesRenogram Phases

I.I. Vascular phase Vascular phase (flow study):(flow study):Ao-to-Kid ~ 3”Ao-to-Kid ~ 3”

II.II. Parenchymal phase Parenchymal phase (kidney-to-bkg): (kidney-to-bkg): TTpeakpeak < <

5’5’

III.III. Washout (excretory) phaseWashout (excretory) phase

Renogram curvesRenogram curves

Evaluation of Evaluation of HydronephrosisHydronephrosis

Diuretic (Lasix) Renal ScanDiuretic (Lasix) Renal Scan

ObstructionObstruction

Obstruction to urine outflow leads to Obstruction to urine outflow leads to obstructive uropathyobstructive uropathy

(hydronephrosis, hydroureter) (hydronephrosis, hydroureter) andand

may lead to may lead to obstructive nephropathyobstructive nephropathy (loss of renal function)(loss of renal function)

Diuretic Renal ScanDiuretic Renal Scan

PrinciplePrinciple Hydronephrosis - tracer pooling in dilated Hydronephrosis - tracer pooling in dilated

renal pelvisrenal pelvis Lasix induces increased urine flowLasix induces increased urine flow If obstructed >>> will not wash outIf obstructed >>> will not wash out If dilated, non-obstructed >>> will wash out If dilated, non-obstructed >>> will wash out

Can quantitate rate of washout (TCan quantitate rate of washout (T1/21/2))


IndicationsIndications Evaluate functional significance of Evaluate functional significance of

hydronephrosishydronephrosis

Determine need for surgeryDetermine need for surgeryobstructive hydronephrosis - surgical Rxobstructive hydronephrosis - surgical Rx

non-obstructive hydronephrosis - medical Rxnon-obstructive hydronephrosis - medical Rx

Monitor effect of therapyMonitor effect of therapy


RequirementsRequirements

Rapidly cleared tracerRapidly cleared tracer

Well hydrated patientWell hydrated patient

Good renal functionGood renal function

Diuretic Renal ScanDiuretic Renal Scan ProcedureProcedure

Pt. preparation: Pt. preparation: prehydration prehydration

adults - oral or 360ml/madults - oral or 360ml/m2 2 iv over 30’ iv over 30’ peds - 10-15 ml/kg D5 0.3-0.45%NSpeds - 10-15 ml/kg D5 0.3-0.45%NS

void before injectionvoid before injection

bladder catheterization ?bladder catheterization ?

Diuretic Renal ScanDiuretic Renal Scan Procedure Procedure (cont’d)(cont’d)

Tracers: Tracers: Tc-99m MAG3 5-10 mCi Tc-99m MAG3 5-10 mCi (preferred over DTPA) (preferred over DTPA)

Acquisition: supine until pelvis fullAcquisition: supine until pelvis full(can switch to sitting post- Lasix) (can switch to sitting post- Lasix)

Flow (angiogram) : 2-3 sec / fr x 1 minFlow (angiogram) : 2-3 sec / fr x 1 min Dynamic: Dynamic: 15-30 sec / frame x 20-30 min15-30 sec / frame x 20-30 min


Void before LasixVoid before Lasix

Lasix: Lasix: 40mg adult, 1mg/kg child iv40mg adult, 1mg/kg child iv

@ ~10-20 min (when pelvis full)@ ~10-20 min (when pelvis full)

oror @ -15min (“F-15” method) @ -15min (“F-15” method)

Acquisition for 30 min post LasixAcquisition for 30 min post Lasix

Assess adequacy of diuresis Assess adequacy of diuresis Measure voided volume Measure voided volume

Adults produce ~200-300 ml urine post-LasixAdults produce ~200-300 ml urine post-Lasix


Don’t give Lasix ifDon’t give Lasix if

Collecting system still fillingCollecting system still filling

Collecting system not full by 60 minCollecting system not full by 60 min

Collecting system drains spontaneouslyCollecting system drains spontaneously

Poor ipsilateral fct (< 20%)Poor ipsilateral fct (< 20%)

pre-Lasixpre-Lasix

post-Lasixpost-Lasix

No UPJ obstructionNo UPJ obstruction

T1/2 T1/2 R = 6’R = 6’L = 2’L = 2’

Post-Lasix curvePost-Lasix curve

Pre-LasixPre-Lasix

10 y/o M

Post-LasixPost-Lasix

Rt UPJ obstructionRt UPJ obstruction

T1/2 T1/2 R = N/AR = N/A

F/U - nephrostomy tube placed

31648973-wk old baby

Lt hydronephrosisLt hydronephrosis

3164897

Lt UPJ obstructionLt UPJ obstruction

Rt UPJ obstructionRt UPJ obstruction

T1/2 T1/2 R = N/AR = N/A

F/U - nephrostomy tube placed

3164897

Lt UPJ obstructionLt UPJ obstruction

Diuretic Renal ScanDiuretic Renal Scan ProcessingProcessing

ROI placementROI placementaround whole kidney around whole kidney ororaround dilated renal collecting system around dilated renal collecting system

T/A curveT/A curve TT1/21/2

from Lasix injection from Lasix injection vs. vs. from diuretic responsefrom diuretic responselinear linear vsvs. exponential fit of washout curve. exponential fit of washout curve

Diuretic Renal ScanDiuretic Renal Scan WashoutWashout

(diuretic response)(diuretic response)

TT1/21/2

time required for 50% tracer to leave time required for 50% tracer to leave the dilated unit the dilated unit

i.e. time required for activity to fall i.e. time required for activity to fall

to 50% of peakto 50% of peak

TT1/21/2 washout washout

cts100%

50%

TT1/21/2 minmin

TT1/21/2 value value Variables influencing TVariables influencing T1/21/2 value: value:

TracerTracerState of hydrationState of hydrationVolume of dilated pelvisVolume of dilated pelvisBladder catheterizationBladder catheterizationDose of LasixDose of LasixRenal function (response to Lasix)Renal function (response to Lasix)ROI (kidney vs. pelvis)ROI (kidney vs. pelvis)TT1/21/2 calculation (from inj. vs. response, curve fit) calculation (from inj. vs. response, curve fit)

TT1/21/2

Normal Normal < 10 min< 10 min Obstructed Obstructed > 20 min> 20 min Indeterminate Indeterminate 10 - 20 min10 - 20 min

Best to obtain own normals for each Best to obtain own normals for each institution, depending on protocol usedinstitution, depending on protocol used

Diuretic Renal ScanDiuretic Renal Scan InterpretationInterpretation

Interpret whole study, not TInterpret whole study, not T1/2 1/2 alone alone

Visual (dynamic images)Visual (dynamic images)

Washout curve shape Washout curve shape (concave vs. convex)(concave vs. convex)

TT1/21/2

Diuretic Renal ScanDiuretic Renal Scan PitfallsPitfalls

False positive for obstructionFalse positive for obstructionDistended bladderDistended bladderGross hydronephrosisGross hydronephrosis

TT(transit time)(transit time) = V = V (volume)(volume) F F (flow)(flow)

Poorly functioning / immature kidneyPoorly functioning / immature kidneyDehydrationDehydration

False negativeFalse negativeLow grade obstructionLow grade obstructionPoorly functioning / immature kidneyPoorly functioning / immature kidney

Effect of catheterization Effect of catheterization (1)(1)

full bladder,no catheter

with catheter in bladder



with catheter without catheter

““F minus 15” F minus 15” Diuretic RenogramDiuretic Renogram

Furosemide (Lasix) injected 15 min Furosemide (Lasix) injected 15 min before before radiopharmaceuticalradiopharmaceutical

Rationale: kidney in maximal diuresis,Rationale: kidney in maximal diuresis,under maximal stressunder maximal stress

Some equivocals will become clearly Some equivocals will become clearly positive, some clearly negativepositive, some clearly negative

English, Br JUrol 1987:10-14Upsdell, Br JUrol 1992:126-132

Captopril Renal ScanCaptopril Renal Scan (ACEI Renography) (ACEI Renography)

Evaluation of Evaluation of Renovascular Renovascular HypertensionHypertension

Renovascular DiseaseRenovascular Disease

Renal artery stenosis (RAS)Renal artery stenosis (RAS)

Ischemic nephropathyIschemic nephropathy

Renovascular hypertension (RVH)Renovascular hypertension (RVH)

RAS RAS RVH RVH

Renovascular Renovascular HypertensionHypertension

Caused by renal hypoperfusionCaused by renal hypoperfusionAtherosclerosisAtherosclerosis

Fibromuscular dysplasiaFibromuscular dysplasia

Mediated by renin - AT - aldosterone systemMediated by renin - AT - aldosterone system

Potentially curable by renal revascularizationPotentially curable by renal revascularization

Renovascular Renovascular HypertensionHypertension

PrevalencePrevalence<1% unselected population with HTN<1% unselected population with HTN

Clinical featuresClinical featuresAbrupt onset HTN in child, adult < 30 or > 50yAbrupt onset HTN in child, adult < 30 or > 50y

Severe HTN resistant to medical RxSevere HTN resistant to medical Rx

Unexplained or post-ACEI impairment in ren fctUnexplained or post-ACEI impairment in ren fct

HTN + abdominal bruitsHTN + abdominal bruits

If these present - moderate risk of RVH (20-30%)If these present - moderate risk of RVH (20-30%)

Renin-Angiotensin SystemRenin-Angiotensin System

RAS

CaptoprilCaptopril

Angiotensinogen

Angiotensin I

Angiotensin II

Aldosterone Vasoconstriction

HTN

Renin

ACE

Effect of RAS on GFREffect of RAS on GFR

Diagnosis of RASDiagnosis of RAS

Gold std: angiographyGold std: angiography Initial non-invasive tests:Initial non-invasive tests:

ACEI renographyACEI renography

Duplex sonographyDuplex sonography

Other tests: Other tests: MRA - insensitive for distal / segmental RASMRA - insensitive for distal / segmental RAS

Captopril test (PRA post-C.) - low sensitivityCaptopril test (PRA post-C.) - low sensitivity

Renal vein renin levelsRenal vein renin levels

ACEI RenographyACEI Renography

Off ACEI & ATII receptor blockers x 3-7 days Off ACEI & ATII receptor blockers x 3-7 days

Off diuretics x 5-7dOff diuretics x 5-7d

No solid food x 4 hrsNo solid food x 4 hrs

Patient well hydratedPatient well hydrated 10 ml/kg water 30-60 min pre- and during test10 ml/kg water 30-60 min pre- and during test

ACEIACEI Captopril 25-50 mg po (crushed), 1 hr pre-scanCaptopril 25-50 mg po (crushed), 1 hr pre-scan

Enalaprilat 40 µg/kg iv (2.5 mg max), 15 min pre-scanEnalaprilat 40 µg/kg iv (2.5 mg max), 15 min pre-scan

Monitor BP q 15 minMonitor BP q 15 min

ACEI Renography ACEI Renography

Patient PreparationPatient Preparation


ProcedureProcedure

Tracer: Tracer: Tc-99m MAG3 (or DTPA)Tc-99m MAG3 (or DTPA) Protocol: Protocol: 1 day 1 day vsvs. 2 day test. 2 day test

1 day test: 1 day test: baseline scan (1-2 mCi) followed by baseline scan (1-2 mCi) followed by post-Capto scan (8-10 mCi)post-Capto scan (8-10 mCi)

2 day test: 2 day test: post-Capto scan, post-Capto scan, only if abnormal >> baseline only if abnormal >> baseline

Acquisition: Acquisition: flow & dynamic x 20-30 min.flow & dynamic x 20-30 min.


ProcessingProcessing

Relative renal uptake (bkg corrected)Relative renal uptake (bkg corrected)

Time to peak (TTime to peak (Tpp) - from cortical ROI) - from cortical ROInormal < 5 minnormal < 5 min

RCARCA2020 (20 min/peak ratio) - from cortical ROI (20 min/peak ratio) - from cortical ROInormal < 0.3normal < 0.3


Grading renogram curvesGrading renogram curves


Diagnostic CriteriaDiagnostic Criteria MAG3:MAG3: ipsilateral parenchymal retention ipsilateral parenchymal retention

p.C.p.C. change in renogram curve by change in renogram curve by 1 grade 1 grade

RCARCA20 20 increase by increase by 15% (e.g. from 30% to 45%) 15% (e.g. from 30% to 45%)

TTp p increase by increase by 2 min or 40% (e.g. from 5 to 7’) 2 min or 40% (e.g. from 5 to 7’)

DTPA:DTPA: ipsilateral decreased uptake ipsilateral decreased uptake Decrease in relative uptake Decrease in relative uptake 10% 10%

(e.g.from 50/50 to 40/60), change of 5-9% - intermediate(e.g.from 50/50 to 40/60), change of 5-9% - intermediate

change in renogram curve by change in renogram curve by 2 grades 2 gradesConsens. report JNM ‘96:1876Semin NM 4/99:128-145


InterpretationInterpretation

High probability RVH (>90%)High probability RVH (>90%)Marked C-induced changeMarked C-induced change

Low probability RVH (<10%)Low probability RVH (<10%)Normal Captopril scanNormal Captopril scan

Abnormal baseline, improved p-C.Abnormal baseline, improved p-C.

Type I curve - pre- and post-C. Type I curve - pre- and post-C.

Intermediate probability RVHIntermediate probability RVHAbnl baseline, no change p-C. Abnl baseline, no change p-C.

Captopril Renal ScanMAG 3MAG 3

Captopril Renal Scan MAG3




In normal renal function - sens/spec ~ 90%In normal renal function - sens/spec ~ 90% In poor renal fct / ischemic nephropathy, In poor renal fct / ischemic nephropathy,

ACEI renography often indeterminate ACEI renography often indeterminate >>> do MRA, Duplex US, angio>>> do MRA, Duplex US, angio

Renal Morphology Scan Renal Morphology Scan (Renal Cortical (Renal Cortical Scintigraphy)Scintigraphy)

Evaluation of Renal Evaluation of Renal InfectionInfection

UTIUTI

VURVURrisk factor for PN, risk factor for PN,

not all pts w PN have VUR not all pts w PN have VUR

PN may lead to scarring >>> ESRD, HTNPN may lead to scarring >>> ESRD, HTNearly Dx and Rx necessaryearly Dx and Rx necessary

Clinical & laboratory Dx of renal involvement Clinical & laboratory Dx of renal involvement in UTI unreliablein UTI unreliable

Renal Cortical ScintigraphyRenal Cortical Scintigraphy


Determine involvement of upper tractDetermine involvement of upper tract

(kidney) in acute UTI (acute pyelonephritis) (kidney) in acute UTI (acute pyelonephritis)

Detect cortical scarring (chronic pyelonephr.)Detect cortical scarring (chronic pyelonephr.)

Follow-up post RxFollow-up post Rx


ProcedureProcedure Tracers Tracers

Tc-99m DMSA Tc-99m DMSA Tc-99m GHATc-99m GHA

AcquisitionAcquisition2-4 hrs post-injection2-4 hrs post-injectionparallel hole posteriorparallel hole posteriorpinhole post. + post. oblique (or SPECT)pinhole post. + post. oblique (or SPECT)

Processing: relative fctProcessing: relative fct


InterpretationInterpretation Acute PNAcute PN

single or multiple “cold” defectssingle or multiple “cold” defectsrenal contour not distortedrenal contour not distorteddiffuse decreased uptakediffuse decreased uptakediffusely enlarged kidney or focal bulgingdiffusely enlarged kidney or focal bulging

Chronic PNChronic PNvolume loss, cortical thinningvolume loss, cortical thinningdefects with sharp edgesdefects with sharp edges

Differentiation of AcPNDifferentiation of AcPN vs vs. ChPN unreliable. ChPN unreliable


“Cold Defect ““Cold Defect “

Acute or chronic PNAcute or chronic PN HydronephrosisHydronephrosis CystCyst TumorsTumors Trauma (contusion, laceration, rupture, Trauma (contusion, laceration, rupture,

hematoma)hematoma) InfarctInfarct

DMSA DMSA parallel hole collimatorparallel hole collimator

Normal DMSA Normal DMSA

pinholepinhole

LPO RPOLPO RPO

DMSADMSA

Acute pyelonephritisAcute pyelonephritisDMSADMSA

post L

LPO pinhole

post R

RPO

LEAP


Congenital AnomaliesCongenital Anomalies

AgenesisAgenesis EctopyEctopy Fusion Fusion (horseshoe, crossed fused ectopia)(horseshoe, crossed fused ectopia)

Polycystic kidneyPolycystic kidney Multicystic dysplastic kidneyMulticystic dysplastic kidney Pseudomasses Pseudomasses (fetal lobulation, hypertrophic (fetal lobulation, hypertrophic

column of Bertin)column of Bertin)

DMSADMSAhorseshoe kidneyhorseshoe kidney

parallel pinhole

DMSADMSALt AgenesisLt Agenesis

parallelparallel

GHAGHACrossed ectopiaCrossed ectopia

74%74%

26%26%

Radionuclide Radionuclide CystogramCystogram


Evaluation of children with recurrent UTIEvaluation of children with recurrent UTI30-50% have VUR30-50% have VUR

F/U after initial VCUGF/U after initial VCUG Assess effect of therapy / surgeryAssess effect of therapy / surgery Screening of siblings of reflux pts.Screening of siblings of reflux pts.

MethodsMethods

Tc-99m S.C. or Tc-99m S.C. or TcO4TcO4

via Foleyvia Foley

can do at any agecan do at any age VUR during fillingVUR during filling

catheterizationcatheterization

Tc-99m DTPA or Tc-99m DTPA or Tc-99m MAG3Tc-99m MAG3

i.v.i.v.

no catheterno catheter info on kidneysinfo on kidneys

need pt need pt cooperationcooperation

need good renal need good renal fctfct

Advant.Advant.

Disadv.Disadv.

Direct Indirect

Direct CystographyDirect Cystography

1 mCi S.C. in saline via Foley1 mCi S.C. in saline via Foley Fill bladder until reversal of flowFill bladder until reversal of flow

(bladder capacity = (age+2) x 30(bladder capacity = (age+2) x 30 Continuous imaging during filling & Continuous imaging during filling &

voidingvoiding Post void imagePost void image RecordRecord

volume instilled volume instilled volume voidedvolume voidedpre- and post- void ctspre- and post- void cts

RN Cystogram vs. RN Cystogram vs. VCUGVCUG

Lower radiation Lower radiation dosedose(5 (5 vs vs 300 mrad to 300 mrad to ovary)ovary)

Smaller amount of Smaller amount of reflux detectablereflux detectable

Quantitation of Quantitation of post-void residual post-void residual volumevolume

Cannot detect distal Cannot detect distal ureteral refluxureteral reflux

No anatomic detailNo anatomic detail Grading difficult Grading difficult

Advantages Disadvantages

Normal cystogramNormal cystogram

filling voiding post-voidfilling voiding post-void

VUR - filling phaseVUR - filling phase

AA

VUR - VUR - voiding phase & voiding phase & post-voidpost-void

BB

Post void residual Post void residual volumevolume

voided vol x post-void ctsvoided vol x post-void cts

pre-void cts - post void ctspre-void cts - post void ctsRV =RV =

Reflux nephropathy

16%16% 84%84%

Documents

Disorders of Renal Function and Edemas