Caritas Family Colleges

(Formerly The Family Clinic, Inc.)

Renal Scan with In-Vitro GFR in Diabetic Nephropathy









Philippine Orthopedic Center
1
st
Semester SY 2014-2015


1. RT EXAM

Renal Scan with In-Vitro GFR
(Kidney Scan, Renogram, Renal Scintigraphy)

2. CASE / PROGNOSIS / DIAGNOSIS

Name: Patient X
Age: 61
Sex: M
Date: February 27, 2013

Clinical information: Elevated Serum Creatinine
(+) Diabetes Mellitus Type 2

Sequential images of the kidneys were obtained after injection of 410 MBq (11.0 mCi) of
Technetium-99m DTPA (Diethylene Triamine Pentacaetic Acid).

Subsequent dynamic images showed normal-sized kidneys with poor cortical tracer
accumulation but adequate elimination. No focal labelling defects were seen in the
renal parenchyma. Minimal amount of urine was noted in the bladder, which eventually
cleared in the post void image.

Both renograms showed low-post perfusion peaks with downsloping elimination
segments.

Glomerular filtration rate values obtained using in-vitro technique with Brochner
Mortensen correction were as follows:
Right kidney - 16.3 ml/min (relative function = 52%)
Left kidney - 15.1 ml/min (relative function = 48%)
Total - 31.4 ml/min
Normalized GFR - 35.3 ml/min/1.73 sqm

Mean normal GFR for age 61 = 96 ml/min.
Lower limit of normal for age 61 = 73 ml/min.
Normal database limited to ages 20 60 years.
Normal range for differential function = 44-56%.

Interpretation:

Normal-sized kidneys with bilaterally depressed perfusion and parenchymal function.
Low total GFR value.
No obstructive pathology.


3. PREPARATION
The physician explains the procedure and offers the opportunity to ask any questions
about the procedure.
Inform patient to notify the radiologist or technologist if allergic to or sensitive to latex,
medications, contrast dyes, or iodine.
The patient is asked to sign a consent form that gives permission to do the procedure.
It is important, prior to having the scan, to have plenty of fluid to drink and are well
hydrated. If not contraindicated, the patient must drink 1-2 glasses of water (500 ml)
within 1 hour before examination. Ask the patient to void before beginning the study.
If the study is being done to evaluate renal hypertension or renal artery stenosis, some
blood pressure medications should be stopped 4-7 days prior to the examination.
Ask the patient to wear a hospital gown, remove jewelry, dentures, and metallic objects
before the scan.
If pregnant or breast feeding, the doctor referring for the renal scan and the radiology
staff where you are having the renal scan must be informed.

4. IMAGE PROCESSING SYSTEM








The computer reconstructs and displays a two dimensional image of the relative spatial
count density on a monitor. This reconstructed image reflects the distribution and
relative concentration of radioactive tracer elements present in the organs and tissues
imaged.

JETStream Workspace is a nuclear medicine image display and processing workstation
that provides software applications used to process, analyze, and display medical
images/data. The results obtained may be used as a tool, by a nuclear physician, in
determining the diagnosis of patient disease conditions in various organs, tissues, and
other anatomical structures. The data processed may be derived from any nuclear
medicine gamma camera.

Data Processing
Place regions of interest over the cortex of each kidney and lateral to or around each
kidney for background subtraction. Place a region of interest over the adjacent aorta.
Generate 20 minute renal cortex and background curves.
Subtract the background curves from the corresponding renal cortex curves. (Be sure
curves are normalized for area, i.e. per pixel, before subtraction.)
Display curves with Timeon X-axis and Countson Y-axis.
The perfusion portion of the time-activity curve should be on an expanded scale
compared to the delayed portion of the curve; this may be done either in one graph if
possible or by using 2 separate graphs.

5. MACHINE AND SPECIFICATION
Philips Dual-Head Gamma Camera









Equipment and Energy Windows
Gamma Camera: Large field of view
Collimator: Low energy, high resolution, parallel hole
Energy window: 20% window centered at 140 keV
Computer


The emission of a single gamma ray is a very small-scale nuclear phenomenon. It is the
role of the gamma-camera head to amplify this microscopic radiation into an electric
signal that can be detected and measured. By exploiting a large number of readings of
these electric signals, one can determine the map of the radioactive nuclei responsible
for the emission of gamma rays.
















The gamma-camera detection head consists of:
Collimator
The collimator is a thick plate of lead or tungsten riddled with a large number of very
thin parallel channels. The gamma rays which can pass through it are those whose
direction is perpendicular to the surface of the lead plate and the scintillating crystal.
The channel axes point towards the body part under examination, and the lead or
tungsten stops all gamma photons travelling at an oblique angle. Other collimators can
be designed using different techniques: a pinhole collimator is used for thyroid
scintigraphy scans, whereas fan-shaped collimators are used for imaging of the brain.

Scintillating Crystal
The detection element at the heart of a gamma camera is a large rectangular crystal of
sodium iodide doped with thallium: NaI (Tl). The crystal has the ability to stop incoming
gamma rays and convert part of the deposited energy into scintillations.

Photomultiplier Tubes
Behind the crystal, an array of small photomultipliers converts photons of light into
electric signals. From the hits in a set of photomultipliers, one can determine the energy
of the incoming gamma rays as well as the approximate position of their impacts on the
crystal. The gamma rays whose energies do not fall within a certain range of the energy
of the radioactive sample (a spectroscopic window) are discarded, and do not
contribute to the final picture.

Position Logistic Circuit and Pulse Height Analyser
Position circuitry receives the electrical impulses from the tubes in the summing matrix
circuit. This allows the position circuits to determine where each scintillation event
occurred in the detector. The amplitude of each electrical pulse from the amplifiers is
measured in the electrical circuits of the pulse-height analyser. Peak height analyser and
a computer convert the light into a useful anatomical image.



Data Analysis Computer
A processing computer is used to deal with the incoming projection data and processes
it into a readable image of the spatial distribution of activity within the patient. The
computer may use various methods to reconstruct an image.
Gantry
All circuits and motors related to movement (longitudinal, rotational, up and down) of
gamma camera are placed in gantry.

6. RADIOGRAPHIC EXAMINATION
Radiopharmaceutical, Dose, and Technique of Administration
Radiopharmaceutical: Tc-99m DTPA (Diethylene Triamine Pentaacetic Acid)
A renal tracer in nuclear medicine introduced in 1970
eliminated by glomerular filtration without undergoing
metabolic alteration. . The biological half-life in plasma of
DTPA chelates in human is about 15 minutes. Over 80% of the
injected dosage can be recovered in urine between 2-3hrs post-
injection. It fulfils most of the requirements necessary for
agents suitable for measuring GFR with the advantage of
being the least expensive renal radiopharmaceutical.

Administered Activity: 400 MBq
Technique of administration: Torniquet method

Patient Position and Imaging Field
Patient Position: Supine
Imaging Field: All of the kidneys and bladder




Acquisition Protocol
Obtain pre-injection count of the syringe with the dose for 1 minute with
shielding.
Place the patient supine with the camera positioned posteriorly.
Use the xiphoid and bladder as landmarks to ensure field of view includes
kidneys and bladder.
Administer the dose by IV bolus. Flush. Record the time of injection.
Phase 1 Flow - Acquire dynamic blood flow images for 1 minute (20 frames at 15
seconds/frame).
Phase 2 Function - Continue dynamic imaging for 19 minutes (76 frames at 15
seconds/frame).
Obtain injection site counts and post-injection counts of the used syringe for 1
minute each, without shielding.
Inform the patient the time of the blood extractions (120 minutes and 240
minutes after administration of the dose)
Obtain a static pre-void image for 1 minute. Have the patient void at the end of
the study (to significantly reduce gonadal radiation dose) then obtain a static
post-void image for 1 minute.
Computer processing: Draw left and right whole kidney ROIs and background
ROIs to determine differential function and to produce renogram curves.


7. RADIATION PROTECTION

Typical set-up/ activities in a nuclear medicine unit of a hospital:

Facilities: imaging machine - gamma camera, PET scanner, radioimmunoassay
laboratory, I-131 therapy

People involved:
Worker - medical oncologist or nuclear medicine physician, medical physicist
and/or radiological health safety officer, technologists/nursing
staff/administrative staff.
General public - patient, companions of patient.

Nuclear medicine includes handling of radioactive materials and subsequent
exposure to radiation.
-requires precautionary measures to ensure:
minimum exposure to occupational personnel and the general public
appropriate exposure to patients.
-procedures must be implemented to prevent contamination from unsealed
sources.
Principles of Radiation Protection
Time - minimize the amount of time spent near a source
Distance - maximize distance from the source (2 meters away)
Shielding - placed between the source and the persons to be protected. e.g.,
Syringe shields, lead bricks, leaded glass, and lead containers

8. DISCUSSION
ANALYTICAL EXPOSITION OF THE CHOSEN RT EXAM AND ITS RELEVANCE TO THE CHOSEN
CASE STUDY:
There is a relationship which exists between diabetes mellitus and raised creatinine levels.
Usually this situation arises when diabetes is there for a long time and not controlled and
this situation is called as diabetic nephropathy, meaning, kidney disease that is a
complication of diabetes. Diabetic nephropathy is caused by damage to the tiniest blood
vessels. When small blood vessels begin to develop damage, both kidneys begin to leak
proteins into the urine. As damage to the blood vessels continues, the kidneys gradually
lose their ability to remove waste products from the blood. Initially this presents as protein
in urine but as the disease progresses, creatinine level goes up.

The renal scan images Tc-99m-DTPA as it passess through the vascular system, renal
glomeruli, renal tubules, and collecting system. The series of images allows the sequential
evaluation of renal perfusion, renal clearance by glomerular filtration, renal parenchymal
transit time, and passage of urine through the renal collecting system. In addition, the study
provides high contrast images for evaluation of renal anatomy. A renal scan may also be
undertaken to evaluate:

Renal tubular function and perfusion (how the body fluids circulate through the kidneys)
Renovascular hypertension (high blood pressure in the arteries of the kidneys)
Renal artery stenosis (narrowing of the arteries that take blood to the kidneys)
Renal tubular obstruction and trauma or damage (blockage or interruption of the
ureters)
For detection of renal masses
For the assessment of the function of a transplanted kidney
For evaluation of possible renal infarct resulting from thrombosis or embolic
phenomena

The scan works by the patient being injected with a radiopharmaceutical. The
radiopharmaceutical is a radioactive compound made up of a radionuclide (Technetium
99m) and a pharmaceutical (DTPA), which influences the biological distribution of the
radionuclide. It involves an injection into a vein in the arm of a small quantity of
radiopharmaceutical preparation. After the intravenous injection, Tc-99m-DTPA enters the
extracellular fluid without diffusing into cells because of its lipid insolubility and negative
charge. It binds for around 10% to the plasma proteins and is almost exclusively removed
from the circulation through glomerular filtration, with negligible extrarenal excretion. A
maximum of 5% in each kidney is achieved 2-3 mins after injection. Images are collected
over three minute intervals. It is filtered through the glomerulus so it is useful in detecting
perfusion of the kidney and glomerular filtration. It then gets extracted by the kidneys, in
the same way that urine is produced, so that it accumulates in the bladder.

The radionuclide aspect of the compound used in renal scanning is Technetium 99m this has
a half-life of approximately 6 hours making it ideal for imaging the kidneys as it gives
enough time to obtain enough information from the scan but is still short enough for the
dose to be safe. Technetium 99m is also very well suited as the gamma rays emitted from it
carry an energy of 140 KeV, which is the optimal energy required to scintillate the sodium
iodide in the gamma camera.

The gamma emitted from the Technetium is then detected by a gamma camera, which then
processes how much radiation is emitted from various areas to construct an image;
mapping the distribution of the radiopharmaceutical and demonstrating renal function. The
gamma camera can detect the radiation coming from the tracer in the kidneys, the ureters
leading from the kidneys to the bladder and the bladder itself. An image is produced of the
kidneys showing what they look like, but also, using the computer attached to the gamma
camera, it is possible to produce a graph showing how well each kidney is working.

The images are read from left to right and from top to bottom. Note that, unlike x-
rays, nuclear renograms show the left kidney on the left side (as you face the scan). The
data collected by the camera is analyzed by a computer and plotted on a time graph. The
darker areas indicate an uptake in the radiopharmaceutical and therefore show which areas
are functioning correctly. Counts (how much isotope is in the kidneys) is shown on the Y axis
and time from injection is shown on the X axis. The response of each kidney is plotted
separately.

Nuclear medicine scans differ from other modalities as they look at cellular function rather
than the gross anatomy of a bone of organ. Unlike other imaging techniques, nuclear
medicine imaging exams focus on depicting physiologic processes within the body, such as
rates of metabolism or levels of various other chemical activity, instead of showing anatomy
and structure. Areas of greater intensity, called "hot spots," indicate where large amounts
of the radiotracer have accumulated and where there is a high level of chemical or
metabolic activity. Less intense areas, or "cold spots," indicate a smaller concentration of
radiotracer and less chemical activity. It is particularly useful when a person is sensitive or
allergic to the contrast medium used in an IVP. It is also useful for analyzing the kidneys as it
demonstrates their function rather than their positional anatomy. This can aid the diagnosis
of certain kidney diseases.


9. REVIEW OF RELATED RESEARCH FINDINGS
Determination of Kidney Function with 99mTc-DTPA Renography Using a Dual-Head
Camera
Madsen Claus J., Mller Michael L., Zerahn Bo, Fynbo Claire, Jensen Jens J.
April 2013


Objective: Single-head gamma camera renography has been used for decades to estimate
kidney function. An estimate of the glomerular filtration rate (GFR) can be obtained
using
99m
Tc-diethylenetriaminepentaacetic acid (
99m
Tc-DTPA). However, because of differing
attenuation, an error is introduced when the kidney depth or kidney size is unequal. This
error can be reduced using geometric mean data obtained from dual-head renography. The
aim of this study was to compare single-head versus dual-head assessment of single kidney
function.

Methods: Thirty-four patients were examined with (a) single-head renography, acquiring
counts from the left ventricle and kidneys from a posterior projection, and simultaneously
with (b) dual-head renography, acquiring counts from the left ventricle from an anterior
projection and kidneys from both anterior and posterior projections using geometric mean
values. Single kidney GFR from both models was estimated (GFRcam1 and GFRcam2,
respectively) and compared with GFR determined with plasma samples of
99m
Tc-DTPA
(GFRps).


Results: The prediction intervals of GFRcam1 and GFRcam2 compared with GFRps did not
differ significantly (SD of GFRcam1-GFRps=17.6 ml/min and SD of GFR2-GFRps=15.5
ml/min; P=0.48). The corresponding coefficients of variation were 16.5 and 14.7%,
respectively.

Conclusion: There is no difference in variance between GFR estimated from single-head
renography and that estimated using dual-head renography. Hence, dual-head camera
renography might be useful in daily practice with the potential to provide a better estimate
of absolute function in each kidney and the relative kidney function in patients with
differing kidney depths and/or malformed kidneys.