RENAL SCINTIGRAPHY IN THE 21st CENTURYCURRENT CLINICAL STATUS of 99mTc-MAG 3-F0 Advantages of the 99mTc-MAG 3-F0 protocol as compared to Old: Easy, Fast, one for All Indications, All

RENAL SCINTIGRAPHY IN THE 21st CENTURY99mTc- MAG3 with zero time injection of Furosemide (MAG3-F0) :

A Fast and Easy Protocol, One for All Indications

IntroductionGeorge N. Sfakianakis MD

Professor of Radiology and PediatricsDirector Division of Nuclear Medicine

HISTORY

Rational Science and Medicine

When the whole thing started?

HISTORYEPICUROSDEMOCRITOSHIPPOCRATES

Father of RationalMedicine

Father of the Atomic Theory of the Matter

Father of Nuclear Scienceand Nuclear Medicine

The Miracle of the 5th Century BC

HISTORY

Modern Atomic Theory

John Dalton 1880

Discovery of Natural and Artificial Radioactivity

Henry Beckerel 1896 Marie Curie 1897

HISTORYGeorg de Hevesy 1913Dmitry I. Mendeleyev 1896Wilhelm C. Roentgen 1895

The first use of radioisotopesin humans

The Tracer Principle The Periodic Table of the ElementsDiscovery of X-Rays 1895

http://www.scienceandsociety.co.uk/results.asp?image=10302157&wwwflag=&imagepos=5

HISTORYErnest O. Lawrence

CyclotronHal AngerBenedict Cassen

Rectilinear Scanner 1950Gamma Camera 1957

Ter-PogossianPET Scanner

RENAL SCINTIGRAPHY

INTRODUCTION

Did you ever want to have one Fast and Easy Protocolfor Scintirenography?

The same for All Indications(Parenchymal and Drainage)

Irrespectiveof the Age of the patient,the degree of impairment of the Renal Function,the general clinical Condition of the patient

And obtain also information about Prognosis

Absolutely Safely and Reproducibly

This is the MAG3-F0 Protocol

Sophisticated Protocols for Renal Scintigraphy

We call “Sophisticated Renal Scintigraphy” the Traditional Methods with Bladder Catheterization

and injection of Diuretic 20-30+ min post radiopharmaceutical

These old traditional methods were inspired before U/S, CT, MRI,were proposed by the experts in the field of renal imaging at the time, endorsed by the Societies – SNM, Pedi Fetal etc - but not revisitedand still followed by many laboratories (due to lack of communication)

We believe these protocols serve the exceptions ratherthan the patient population we currently evaluate in Nuclear Medicine

Problems with theSophisticated Protocols for Renal Scintigraphy

• Patient Preparation is Painful and potentially Dangerous(Bladder Catheterization and IV hydration)

• Studies are Too Lengthy (40min-60min)• The radiation Exposure to the gonads is higher• Diagnosis for Cortical problems is not obtained• Prognosis is not usually possible

As a result renal scintigraphy has always been and still is underutilized

Sophisticated Protocols for Renal Scintigraphy

Father: “Better operate on my child than ask for a nuclear study”

(Testimony of Dr Ricardo Gonzalez, Pedi-Urologist)

Those who practice pediatric nuclear medicine had these concerns

since the seventies and eighties

Current Status of Renal Scintigraphy

Variety and complexity of Radiopharmaceuticals and Protocols

Referring Physicians (urologists, nephrologists, internists, surgeons),Radio-Pharmacists, Technologists, and involved Administratorsalong with Nuclear Medicine Practitioners and Radiologistsare all confused by the large number of Radiopharmaceuticalsand the great variety and complexity of the different Protocolsfor Renal Scintirenography, which is in general, underutilized.

We addressed this long ago and we have identified and applied The BEST Radiopharmaceutical and a single EASY protocol

THE NEED FOR A NEW PROTOCOL

There has always been a need for

• a single, easy, fast and simple protocol

• patient and technologist friendly

• to provide information about drainage

• and also about focal and global renal cortical function

Recent improvements in patient care, other methods (US) and

economic issues had made this protocol mandatory

Recent Improvements in Other Imaging Modalitieswhich threaten the use of the Sophisticated Scintigraphy

• UltrasoundImproved Resolution - DopplerThree DimensionalContrast Agents

• Computed TomographySpiral CTDynamic Studies with ContrastCT-Angiography

• Magnetic Resonance ImagingGFR Contrast Dynamic StudiesMR-AngiographyMR-Renography

Methods :Methods :Combined StaticCombined Static--Dynamic MR UrographyDynamic MR Urography

W. K. Rohrschneider

Post processingPost processing

There has always been a need for an easy and simple protocol

But recent improvements in patient care and economic issues

have made this need mandatory

THE FAST PROTOCOL:It began at OSU and continued at UM first as Hippuran-F3

and when MAG3 became available (1988) as 99mTc-MAG3-F0

THE UNIVERSITY OF MIAMI APPROACH

RENAL SCINTIRENOGRAPHY

IN THE 21st CENTURY

99mTc- MAG3 with zero time injection of Furosemide

( MAG3-F0 )

A Fast and Easy Protocol, for drainage and cortex

One for All Indications and all ages

RENAL SCINTIGRAPHY AT UM/JMMC: (MAG3-F0) Method applied the last 18 years:

• One only Protocol: Simple, Easy and Fast (22 min) :

-No Bladder Catheterization / Oral Hydration

-One Injection (MAG3 and Diuretic simultaneously = F0)

-The Same Protocol for All Indications (APN) since 1994

-It serves the vast Majority of Cases (not the Exceptions)

• Education of Referring and User Physicians

• Participation in Clinical/Educational Activities of Clinicians

• Research and Publications with Clinicians

Results: 7-15 renal studies per day the last few years

BASIC PRINCIPLE FOR THE NEW PROTOCOL: (MAG3-F0)

• Furosemide given IV:

Diuretic Effect begins between 4 - 5 min

Maximum Effect at 9 min

PRECIOUS INFORMATION from MAG3-F0

Morphologic and Functional Information(regional/global)in All Ages and Functional States including Renal FailureFor Congenital or Acquired diseases including TransplantsEssential for Diagnosis, Prognosis and Follow-Up about:

Renal Blood Flow:First pass study images, Flow Velocity Index quantified

Renal Parenchymal (cortical) function:Focal Disorders visualized, Global Function quantified

Intra/Extra-Renal Drainage System:Morphologic changes visualized, Drainage quantified

MAG3-F0 is Technically Easy/ Safe/Acceptable/Affordable

CURRENT CLINICAL STATUS of 99mTc-MAG3-F0

Advantages of the 99mTc-MAG3-F0 protocol as compared to Old:

Easy, Fast, one for All Indications, All Ages, All Kidney Disorders

At the UM we perform 7-15 renal scintigraphic studies per day

Disadvantages of Renal Scintigraphy in general

experienced also with the MAG3-F0 protocol :

• Biologic Limitations (tumors, stones, calcifications, resolution)

• Unfamiliarity among referring and user doctors (elsewhere)

• Correlative Imaging Modalities successful(U/Sound, CT, MRI)

TO OBTAIN BEST RESULTS

WITH THE FAST PROTOCOL

WE NEED TO EMPLOY

THE BEST RADIOPHARMACEUTICAL

Which one is the best?

WITH THE BEST PROTOCOL


RENAL RADIOPHARMACEUTICALS 99mTc-MAG3:……….Tubular Excretion (EE = 60%)

Global Dynamic Tubular Function Imaging

123/131I-o-Hippurate:..GF and TE (EE = 80%)Dynamic ERPF Imaging

99mTc-DTPA:……….Glomerular Filtration (EE = 20%) Dynamic Imaging of GFR

99mTc-DMSA:………Cortical Fixation(GF and reabsorption)(EE = 5%)Parenchymal Function Imaging

99mTc-GH:…………..Combined GF and Cortical Fixation (EE = 20%) Dynamic GF and Parenchymal Imaging

Comparison Between99mTc-MAG3 and 123/131I-o-Hippurate

Misunderstanding

Ye have heard that it was said by them of old time:DTPA is a good imaging agent for kidneys

But we say unto you MAG3 is a much better agent for renal scintigraphy

ADVANTAGES of MAG3 for RENAL SCINTIGRAPHY

• High Renal Extraction Efficiency 60%

Fast parenchymal accumulation

Fast background clearance

Effective Parenchymal Imaging (early/late e.g.: APN)

Accurate evaluation of Intra/Extra Renal Drainage

• Small Distribution Space

Steep (sensitive) Renograms

• Technetium-99m-Chemical Labeling

High dose, Good statistics, Low radiation exposure

• Safe (experience 18 years)

COMPARISON of MAG3 with DTPA

Congenital Anomalies(Cross Ectopia)

MAG3 DTPA

MAG3 COMPARISON TO DTPA

MAG3 DTPA

1) KIDNEY HANDLING TUBULAR GLOMERULAR


MAG3 DTPA

1) FUNCTION TUBULAR GLOMERULARVisualizes Kidney when no GF(ATN, Total obstruction, toxicity): Successful No visualizationVisualizes Focal Lesions(APN, dysfunction etc): Hot Spot Cold Spot(?)


MAG3 DTPA

2) EXTRACTION EFFICIENCY 60% 20%


MAG3 DTPA

2) EXTRACTION EFFICIENCY 60% 20%Parenchymal Evaluation(Rejection, Nephrotic, Nephritic etc) Successful MediocreStudy of Drainage(Diuretic Renography etc): Successful Mediocre Patient Radiation (Radiation exposure of the patient): Lower Higher

MAG3 COMPARISON TO DTPAMAG3 DTPA

1) FUNCTION TUBULAR GLOMERULARVisualize Kidney when no GF(ATN, Total obstruction, toxicity): Successful No visualizationVisualize Focal Lesions(APN, dysfunction etc): Hot Spot Cold Spot(?)

2) EXTRACTION EFFICIENCY 60% 20%Parenchymal Evaluation(Rejection, Nephrotic, Nephritic etc) Successful MediocreStudy of Drainage(Diuretic Renography etc): Successful Mediocre Patient Radiation (Radiation exposure of the patient): Lower Higher


Finally it was Recognized to be 99mTc - MAG3

THE PROTOCOL


OUR EXPERIENCE PROVES THATTHE BEST PROTOCOL IS

99mTc- MAG3 with zero time injection of Furosemide: MAG3-F0


Selected to be 99mTc - MAG3

THE PROTOCOL

99mTc- MAG3 with zero time injection of Furosemide: MAG3-F0

This protocol addresses the majority of cases (>99%)

MAG3-F0 Protocol Next Summer: Day Sessions in Greece

MAG3-F0 Protocol Next summer: Night Sessions in Greece

THE FAST PROTOCOL:It began at OSU and continued at UM first as Hippuran-F3

and when MAG3 became available (1988) as 99mTc-MAG3-F0

RENAL STUDIES: PROTOCOL AT UM/JMH99mTc-MAG3-F0 (or MAG3-F0 )

No difficult Patient Preparation is needed

No Sedation (only restriction of motion)

Hydration 5-10 ml/kg water orally or iv at –30 min

No Bladder Catheterization (except in selected cases)

Study either supine or upright

PROTOCOL FOR MAG3 - F0

PATIENT PREPARATIONEasy (only restriction, oral hydration, no bladder cath.)

DYNAMIC STUDY (iv 1-10 mCi MAG3 + 40-80 mg LASIX)Simultaneous injection of Furosemide: MAG3-F0Duration of the study 25 min

TOMOGRAPHY-SPECT (20 mCi MAG3)No diuretic neededDuration of the study 4 min


A. DYNAMIC STUDY

Injection iv 1-10 mCi MAG3 + 40-80 mg LASIX (Furosemide)

Simultaneous Injection of MAG3 and Lasix = F0

ACQUISITION: FLOW: 1 min ( 1 frame per 1 sec)

FUNCTION: 22 min ( 1 frame per 30 sec)

POST VOID 2 min static image (at 25-30 min)

DELAYED 2 min static images (at 1 hr)

GROUPING IMAGES : -FLOW: in 3 sec images

-FUNCTION: in 2 min images

GRAPH GENERATION: -FLOW/FUNCTION, KIDNEY/CORTEX


FOR NATIVE KIDNEY STUDIES FOR RENAL TRANSPLANT STUDIES

PROTOCOL #2 FOR MAG3 - F0

B. TOMOGRAPHIC (SPECT) STUDY

(evaluates Cortical Anatomy in 3D, Ectopias, Split RF)

Injection iv 2-20 mCi MAG3 No Lasix needed

Acquisition of the study 4min

QUANTIFICATION

TIME ACTIVITY GRAPHS(flow/function/drainage)

SPLIT RENAL FUNCTION

GLOBAL RENAL FUNCTION (CLEARANCE)

TIME ACTIVITY GRAPHS OF SCINTIGRAPHY

a) Renal Blood Flow Graph1 sec/point for 30-60 secFirst Pass Renal Perfusion Activity

b) Renogram (Cortical or Kidney including Pelvis)30 sec/point for 24 minBalance of feed in-uptake-discharge activity

REGIONS OF INTEREST: NATIVE KIDN. AND TRANSPLANTS

for kidneys for cortex background 2 background 3

for flow for kidney for cortex

TIME ACTIVITY GRAPHS:

BLOOD FLOW GRAPHS

TIME ACTIVITY GRAPHS:

KIDNEY GRAPHSand

CORTICAL GRAPHS

EVALUATION OF TIME/ACTIVITY GRAPHS

a) Visual Evaluation in most cases

b) Simple Indices in all casesi. Flow Velocity Index

ii. OCA (2.5/20min), Tpeak, T-1/2, RCA (20/peak)

c) Sophisticated Mathematical Analysisi. Mean Transit Time (Flow)ii. Deconvolution Analysis (Renogram)

d) Computer Automationi. Neural Networksii. Artificial Intelligence

FLOW VELOCITY INDEX = 0.9

FLOW GRAPHS

FLOW VELOCITY INDEX

NORMAL GRAPHS

RENOGRAMS

RCA AND OCA

Documents

RENAL SCINTIGRAPHY IN THE 21st CENTURYCURRENT CLINICAL STATUS of 99mTc-MAG 3-F0 Advantages of the 99mTc-MAG 3-F0 protocol as compared to Old: Easy, Fast, one for All Indications, All