1 The Society of Nuclear Medicine and Molecular Imaging (SNMMI) is an international

2 scientific and professional organization founded in 1954 to promote the science, technology,
3 and practical application of nuclear medicine. The European Association of Nuclear
4 Medicine (EANM) is a professional nonprofit medical association that facilitates
5 communication worldwide between individuals pursuing clinical and research excellence in
6 nuclear medicine. The EANM was founded in 1985. SNMMI and EANM members are
7 physicians, technologists, and scientists specializing in the research and practice of nuclear
8 medicine.
9 The SNMMI and EANM will periodically define new guidelines for nuclear medicine
10 practice to help advance the science of nuclear medicine and to improve the quality of
11 service to patients throughout the world. Existing practice guidelines will be reviewed for
12 revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.
13 Each practice guideline, representing a policy statement by the SNMMI/EANM, has
14 undergone a thorough consensus process in which it has been subjected to extensive review.
15 The SNMMI and EANM recognize that the safe and effective use of diagnostic nuclear
16 medicine imaging requires specific training, skills, and techniques, as described in each
17 document. Reproduction or modification of the published practice guideline by those
18 entities not providing these services is not authorized.
19
20 Developed 2013
21
22 THE SNMMI AND EANM PRACTICE GUIDELINE FOR RENAL SCINTIGRAPHY IN
23 ADULTS
24
25
26 Authors: Chairman M. Donald Blaufox, Co-Chairman Diego De Palma committee: Yi Li,
27 Alain Prigent, Martin Samal, Andrea Santos, Zsolt Szabo, Andrew Taylor, Giorgio
28 Testanera, Mark Tulchinsky
29
30
31 Keywords:
32
33
34 PREAMBLE
35 The Society of Nuclear Medicine and Molecular Imaging (SNMMI) and the European
36 Association of Nuclear Medicine (EANM) have written and approved guidelines to promote the
37 use of nuclear medicine procedures with high quality. These guidelines are intended to assist
38 practitioners in providing appropriate nuclear medicine care for patients. They are not inflexible
39 rules or requirements of practice and are not intended, nor should they be used, to establish a
40 legal standard of care. For these reasons and those set forth below, the SNMMI and EANM
41 caution against the use of these guidelines in litigation in which the clinical decisions of a
42 practitioner are called into question.
43
44 The ultimate judgment regarding the propriety of any specific procedure or course of action must
45 be made by medical professionals taking into account the unique circumstances of each case.
46 Thus, an approach that differs from the guidelines does not necessarily imply that the approach
47 was below the standard of care. To the contrary, a conscientious practitioner may responsibly
48 adopt a course of action different from that set forth in the guidelines when, in the reasonable
49 judgment of the practitioner, such course of action is indicated by the condition of the patient,
50 limitations of available resources, or advances in knowledge or technology subsequent to
51 publication of the guidelines.
52 The practice of medicine involves not only the science, but also the art of dealing with the
53 prevention, diagnosis, alleviation, and treatment of disease. The variety and complexity of
54 human conditions make it impossible at times to identify the most appropriate diagnosis or to
55 predict with certainty a particular response to treatment. Therefore, it should be recognized that
56 adherence to these guidelines will not assure an accurate diagnosis or a successful outcome. All
57 that should be expected is that the practitioner will follow a reasonable course of action based on
58 current knowledge, available resources, and the needs of the patient to deliver effective and safe
59 medical care. The sole purpose of these guidelines is to assist practitioners in achieving this
60 objective.
61
62
63
64 INTRODUCTION
65 Renal scans are safe and widely available tests that provide information about the morphology
66 and function of the kidneys utilizing of radiopharmaceuticals with high renal clearance
67 (Sfakianakis, 1988). This information supplements those that obtained by other imaging tools
68 methods (Ultrasound, CT, MRI) (Boubaker 2006, De Palma 2014), especially regarding theit
69 has special value to measure relative renal function.al balance between the kidneys, about the
70 effect of aAnatomical abnormalities affecting causing renal vascularity or the urinary tract
71 malfunctionon renal functioncan be clarified,. sometimes using theThis potential can be
72 enhanced with pharmacological of drugs to that stress the systemrenal functional capability..
73 Radiopharmaceuticals used to perform renal scans can be divided into three major categories:
74 filtrated filtered by the glomerulus, secreted by the tubules and retained in the tubules via
75 receptor-mediated endocytosis.
76 Functional agents (filtered by the glomerulus and or secreted by the tubules) are used in the
77 dynamic renal scan (or renography), and morphological agents (retained in the tubules) are used
78 in the static (cortical) renal scan.
79 Dynamic scans shows elucidate the uptake and drainage of the radiopharmaceutical, and allows
80 the generation of time-activity curves by selection of regions of interest, whilst while static scans
81 depictsimage the functional renal tissue and may provide useful morphologic information.
82 An uUnderstanding of the principles of the test, its limitations and the sources of error are
83 essential in to the interpretation of the results and effective use of itrenal scintigraphy.
84
85 GOALS
86 Purpose of this guideline is to give toprovide practitioners a complete summary of
87 radiopharmaceuticals, techniques and consolidated clinical indications for performing renal
88 scintigraphy in adults. This state-of-the-art overview will not deal with radiopharmaceuticals or
89 indications currently under investigation or used for clinical trials or research.
90
91 DEFINITIONS
92 Not applicable
93
 94 COMMON CLINICAL INDICATIONS
95 Major indications (Blaufox 1991) for renal scintigraphy include (Blaufox 1991) but are not
96 limited, to the following:
97 Calculation of the differential (relative) renal function,
98 Measurement of the absolute renal function, either as an approximation of effective renal
99 plasma flow (ERPF) or glomerular filtration rate (GFR).
100 Congenital and acquired renal abnormalities
101 Acute renal failure
102 Obstructive uropathy
103 Renovascular hypertension
104 Status post renal transplantation
105 Pyelonephritis and parenchymal scarring
106
107 Optimal assessment aboutof the existence of an obstructive uropathy normallyusually requires
108 Diuretic diuretic renography (Rado JP, el al 1968, OReilly PH, et al 1978, 1992, 1996), i.e. the
109 use of a diuretic drug, such as furosemide, for to maximizing theinitiate a diuresis. This test has
110 become one of most common procedures in daily renal nuclear medicine practice, and is very
111 useful in differential differentiation of obstructive or non-obstructive causes of a dilated renal
112 pelvis (Taylor 2012)., being Diuretic renography is a non-invasive equivalent to the now
113 discarded Whitaker test, which directly measures the intrarenal pelvic hydrostatic pressure.
114 There is a full guideline in preparation devoted to obstructive uropathy.
115
116 In the case of a suspected renovascular hypertension, it is recommended to perform an an
117 aAngiotensin-converting enzyme inhibition (ACEI) renographyrenogram,. This was first
118 described in 1983 by Majd et all (Majd M, et al 1983). This test ishelps able to diagnose renal
119 vascular hypertension caused by renal artery stenosis (RAS) and to may predict the response to
120 vascular intervention. ACEI renography has been used as a routine nuclear medicine exam for
121 many years. In the era of CT angiography, MR angiography and Doppler vascular sonography
122 the role of captopril renography has changed diminished (Taylor A. 1996, 2006; Prigent 2014).
123
124 The renal transplant with ATN has poor renal function with evidence of renal cortical retention
125 of MAG3, poor reduced renal uptake of DTPA and poor reduced urine excretion butwith
126 images showing its blood perfusion is relatively better than itspreserved compared to function
127 (Hilson AJ et al 1978, Kirchner PT et al 1978, Li Y, Russell CD, et al 1994). Quantitative
128 methods may be useful in follow-up studies. There are a variety of methods proposed to
129 quantitate evaluate blood flow curve of the transplant kidney, such asincluding Hilson et als
130 perfusion index and Kirchner et als kidney-to-aorta (K/A) ratio (Hilson AJ et al 1978, Kirchner
131 PT et al 1978). There are quantitative methods for measurement of renal parenchymal (cortical)
132 retention of tubular radiotracers (MAG3 and OIH), such as Tmax and 20/3 min ratio (Li Y,
133 Russell CD, et al 1994) which increase in ATN of the graft. A comprehensive review was
134 published by Dubovsky et al. (1999) Formatted: Font color: Auto
135
136 1. Urinary tract infections (UTI) are often clinically only divided as into febrile or non-febrile.
137 Tc-99m DMSA is the best imaging agent to visualize renal parenchymal pathology, allowing
138 helping Pyelonephritis to be distinguished pyelonephritis from lower tract febrile infections
139 acutely. , when performed during the acute phase of the illness. Renal cortical scintigraphy y
140 is usually may be performed to evaluate kidney scarring after pyelonephritis. Scarring must
141 beshould not be assessed not beforeless than six months after the last febrile UTI. (De Palma,
142 2013)
1432.
144 QUALIFICATIONS AND RESPONSIBILITIES OF PERSONNEL
145 In the United States, see Section V of the SNMMI Guideline for General Imaging. In Europe, the
146 certified nuclear medicine physicians who perform the study and sign the report are responsible
147 for the procedure, according tocomplying with national laws and rules.
148
149 PROCEDURE/SPECIFICATIONS OF THE EXAMINATIONS
150 Request
151 The request for the study should include all relevant clinical, laboratory and imaging
152 information. In particular, the nuclear medicine physician should be aware of relevant urologic
153 procedures and surgeries such as the presence of a nephrostomy tube, ureteral stent and or
154 urinary diversion. .
155 The supervising/interpreting nuclear medicine physician should review all available clinical,
156 laboratory, and radiologic data prior to performing the study.
157
158
159A. Patient preparation and precautions
160 Renal radionuclide scans generally require no specific preparation:; patients must can avoid
161 fasting, and drinking at least 500 ml of water is recommended. Pregnancy is a usually a
162 contraindication to every radiopharmaceutical administration. Adverse reactions to renal
163 radiopharmaceuticals are quite uncommonrare;: no major reaction has ever been reported
164
165B. Radiopharmaceuticals
166 For When performing the dynamic renal studies, the radiopharmaceuticals can be sub-divided
167 into two categories: 1: High eExtraction rRenal pPlasma fFlow (Approximate ERPF) agents
168 (tubular extraction) including : 131 I-hippuran, 123 I-hippuran, 99mTc-MAG3 (mercaptoacetyl-
169 triglycerine) and 99mTc-EC (ethylenedicysteine). (5,6) Commented [MDB1]: Fix reference
170 and 2: gGlomerular fFiltration agents,: including 99mTc-DTPA (diethylenetriamine pentaacetic
171 acid) and 51-Cr EDTA (ethylendiamine tetraacetic acid)
172 For renal morphologic scintigraphy, Tthe radiopharmaceuticals used for renal morphologic
173 scintigraphy, are 99mTc-DMSA (dimercaptosuccinic acid) and 99mTc-glucoheptonate, both
174 accumulating of which accumulate primarily into the renal cortex.
175
176 I-131/123 orthoiodohippuran (OIH), is a classic renal tubular agent that has been used as a
177 substitute for para-aminohippurate (PAH), which was introduced by Tubis (Tubis M, et al,
178 1960). The 131-I label, once used for probe renography, gives yields very low quality images
179 with a high radiation dose and is no longer available.
180 Tc-99m MAG3 (Fritzberg AR, et al, 1986), is similar to OIH (Russell, 1999), although it has
181 having novery little glomerular filtration due to its high plasma protein binding, that results in a
182 lower extraction fraction. (Muller-Suur, 1989). Tc-99m MAG3 now becomes the daily usedis
183 currently the most frequently used Tc-99m labelled renal tubular agent in nuclear medicine
184 practice. For Since its excretion, is more comparable to the secretion rate of proximal renal
185 tubule, Bubeck et al proposed the concept of tubular extraction rate (TER) (Bubeck B, et al,
186 1987) to replace the term ERPF.
187
188 Tc-99m DTPA is excreted by glomerular filtration without renal tubular secretion, the same
189 waysimilar to of inulin and creatinine, and was first clinically used clinically in 1970 (Hauser W.
190 et al 1970). There is only 5-10% protein binding bound DTPA in the plasma at after1 hour.
191 DTPA labelled with Tc-99m remains the most suitable radiopharmaceutical for routine
192 combined measurement of GFR and renal imaging.
193
194 Cr-51 EDTA also has been also commonly used in Europe since 1966 to measure GFR (Stacy
195 BD 1966, Chantler, 1972), Iit is not available in the US and it cannot be used for imaging.
196
197 Tc-99m DMSA (dimercaptosuccinic acid) (Lin TH, et al 1974) and Tc-99m GH
198 (glucoheptonate) (Boyd RE. et al 1973) were proposed in early 1970s. They are mainly bound in
199 the proximal tubule in the renal cortex for a prolonged time after injection and are suitable for
200 static renal imaging to demonstrate renal mass or defects in the renal parenchyma. These agents
201 are also called renal cortical agents. 99mTc-DMSA is commonly used because of its bigger
202 higher retention in the renal parenchyma (30% vs 5-10% of glucoheptonate). (Willis, 1977)
203 These numbers are approximations and there is some evidence of secretion of DMSA by the
204 distal tubule (Yee et al 1981). Because of its high retention the potential radiation dose of DMSA
205 is significant and the administered dose should be chosen with that in mind.
206
207 PROTOCOL/IMAGE ACQUISITION
208 Static Renal Scan (sometimes referred as Renal Cortical scintigraphy
209 Radiopharmaceutical and injected activity: 99mTc-DMSA provides the best images. 99mTc-
210 Glucoheptonate has been used also.,
211 Adult Dose: 100 MBq
212 Radiation burden: approximately 1mSvv. (ICRP 80, 1998).
213 General procedure:
214 Previous Information
215 All relevant available clinical, biochemical and imaging information must be collected.
2163. Patient preparation:
217 Good hydration before and after radiopharmaceutical administration
218 Radiopharmaceutical Administration:
219 Intravenous injection should mustbe performed, carefully avoiding extravasation.
220 Timing after injection:
221 Image acquisition should start from 2 to 4 hours after radiopharmaceutical
222 injectionadministration. In case of lowIn the presence of poor renal function late images (up to
223 20 hours after) can be acquired.
224 Patient Positioning
225 Supine position.: Be careful with patient comfort, to reduce motion.
226 Technical Parameters:
227 Static images acquisition
228 Collimator: HighLow energy, ultra-high Resolution or pinhole (in small children)
229 Minimum Matrix for dynamic scan: 128x128 or 256x256 pixel (newer instruments permit much
230 greater resolution)
231 Zoom: From 1 to 2
232 Total counts/ Time per view: At least 300 000 total counts must be acquired or use fixed time of
233 5-10 minutes/ per view. If a pinhole collimator is being used, 100 000 to 150 000 total counts or
234 10 minutes should be acquired per view.
235 Views: Posterior and 30-35 Posterior Obliques. Anterior view must be acquired inconsidered if
236 there are abnormalities of number, shape and position of the kidneys. SPECT images can be
237 acquired but there is no consensus in its usefulness (Piepsz, 2001)
238 After Imaging:
239 Patient should be advised to maintain hydration and frequent bladder emptying during the rest of
240 the day.
241 Renal dynamic scintigraphy
242 Renal dynamic scintigraphy (sometimes referred as radionuclide renography) refers toconsists of
243 serial imaging after intravenous administration of the selected radiopharmaceutical. This
244 procedure usually involves 2 serial dynamic acquisitions, the first intended to investigate
245 vascular or perfusion phase (this phase is often omitted), followed by the second one needed to
246 evaluatefor functional uptake, cortical transit, and excretion phases. It is recommended also to
247 obtain a a later static imageing after upright standing and bladder voiding. Although these phases
248 are often discussed separately, they all take place virtually simultaneously.
249 Patient preparation:
250 Good hydration before and after radiopharmaceutical administration is essential. Empty theThe
251 patient should void bladder before the beginning of the scan.
252
253
254
255 General adult activityAdult Dose: 99mTc-labeled radiopharmaceuticals: from 90 to 200 MBq.
256 The higher activity is suggested for studying renal perfusion, 123-I Hippuran: 74 MBq
257 We strongly recommend optimizing protocols according to the ALARA principles
258 Radiation burden: usually, approximately less than 1mSv with the above suggested activities.
259 (ICRP 80, 1998; Stabin, 1992). Specific information is detailed in Tables 1 and 2.
260 General procedure:
261 Previous Information
262 All relevant available clinical, biochemical and imaging information must be collected.
263 Radiopharmaceutical administration
264 Intravenous injection should be performed. BA butterfly needle is recommended to avoid
265 extravasation. If requested indicated by clinical indications, furosemide intravenous
266 administration can be performed. The sSuggested dose is 0.5 mg/kg of body weight, max 40 mg.
267 Administration may happen in different moments. The simplestr practice is to administer it the
268 diuretic at the same time as the radiopharmaceutical (so called F+0 protocol). Is it possible
269 toOther options include administer it 20 minutes after radiopharmaceutical injection or 15
270 minutes before radiopharmaceutical injection (so called F+20 or F-15 protocols). Interpretation
271 of the results must take into account the chosen timing.
272 For clinical indication of rRenovascular hypertension scintigraphy is performed approximately 1
273 hour after oral administration of 25 to 50 milligrams of captopril or 10 to 20 minutes after
274 intravenous injection of 40 micrograms/kg (maximum 2.5 mg) of enalaprilat. Blood pressure
275 should be measured before administration of the ACE inhibitor and monitored every 10 to 15
276 minutes. An intravenous line should be considered to be kept in place to allow prompt fluid
277 replacement if the patient becomes hypotensive. The patient should be well hydrated, especially
278 if furosemide is also used to facilitate detection of cortical retention of the radiopharmaceutical.
279 One protocol is to obtain a baseline scan without an ACE inhibitor followed by a repeat
280 examination after administration of an ACE inhibitor on the same or following day. The
281 combined examinations help to detect significant ACE inhibitor induced scintigraphic
282 abnormalities. (Fommei, 1993, Taylor AT Jr, et al 1998)
283 An alternative protocol is to obtain the examination with an ACE inhibitor first. A normal
284 examination indicates a low probability for renovascular hypertension and obviates the need for
285 a baseline examination without an ACE inhibitor. If the examination with an ACE inhibitor is
286 abnormal, a baseline examination is needed as further investigation waiting at least the next day
287 or later. Chronic use of ACE inhibitors may decrease the sensitivity of the test. ACE inhibitors
288 should be discontinued for 3 to 7 days before the test, depending on their half-life. If stopping the
289 patients ACE inhibitor is not possible, the study may still be performed. (Fommei, 1993) but the
290 sensitivity is decreased.
291 Timing after injection and scan framing:
292 A commonly used technique involves dynamic acquisition of 1-2 second images for 1 min.
293 (vascular phase (first phase)), starting immediately after radiopharmaceutical administration. It is
294 followed by 10-20 second images (functional uptake , cortical transit (second phase),), and then
295 20-30 sec. images (excretion phases (third phase)). Always acquire a post-micturition post-erect
296 image, for the same time duration of as the last frame of the renogram. The compatibility
297 between the acquisition protocol and the processing software must be checked in advance.
298 Patient Positioning
299 Supine position: Be careful with patient comfort, to reduce motion. In patients with
300 particularwho cannot lie flat clinical condition is it is possible to perform the exam seated with
301 the back on gamma-camera detector, but this may lead to important errors
302 Technical Parameters
303 Dynamic images acquisition
304 Collimator: [Low Energy High resolution or General purpose, according to availability
305 Minimum Matrix: 64x64 or 128 x128 pixel
306 Zoom: 1
307 Views: Posterior. Anterior views must be acquired in the presence of horseshoe or ectopic
308 kidney conditions or in other particular requestssituations where the kidney is anterior such as
309 kidney allograft evaluation. Lateral views may be obtained at the end of the renography if renal
310 depth measurements are requested needed.
311 Frame time (flowfirst phase): 1-5 seconds/frame for 1 minute
312 Frame time (functionsecond phase): 10-20 seconds/frame for 5-10 minutes
313 Frame time (excretionthird phase): 20-30 seconds/frame for at least 20 min
314 Total max time 20-30 minutes
315 Additional images after bladder emptying or delayed post-erect images, of the same duration of
316 as the last frame of the renogram are useful.
317 After Imaging
318 Patient should be advised to maintain hydration and frequent bladder emptying during the rest of
319 the day.
320
321 C. Processing Formatted: No bullets or numbering, Tab stops: Not at 1"
322
323 Split (relative, differential) renal function
324
325 The aAccuracy and reproducibility of the measurement of split renal function (SRF) depends on
326 kidney size and kidney function. The sSmaller the kkidneys and those with e lower theirreduced
327 function, are associated with the lower the accuracy and precision of the measurement of split
328 renal function. Other factors affecting accuracy are intrarenal vascular and extra-renal
329 (extravascular and vascular) background, attenuation, and scatter. Main sources of error in the
330 measurement of split renal function are background activity and attenuation [Piepsz, 1990;
331 Lythgoe, 1999; Caglar, 2008; Lezaic, 2008].
332
333 The measurement of SRF with static renal scintigraphy requires the tracing ofdrawing a Rregion
334 of Iinterest (ROIs) around each kidney and to calculate the percent contribution of each kidney
335 counts to total counts. The subtraction of area-normalized background ROIs is not strictly
336 necessary in patients with good renal function, whilst but it is mandatory in case of poor renal
337 function (Piepsz,2001) Unfortunately, in the case of poor renal function the errors of the
338 measurement increase. (Fine EJ, Blaufox MD On Behalf of the Albert Einstein College of
339 Medicine/Cornell University Medical Center Collaborative Hypertension Group 1991)
340
341 The measurement of SRF with dynamic renal scintigraphy requires the tracing ofdrawing a
342 rRegion of iInterest (ROIs) around each kidney and the generation of curves (renograms) from
343 each ROI after the subtraction of area-normalized background ROIs. The most accurate
344 background ROIs are C-shaped surrounding the lower, lateral and upper part of the kidney. The
345 SRF is then calculated with a mathematical algorithm applied to the uptake part of the curve.
346 The recommended time periods are
347 60-120 after the appearance of the tracer in the aorta for 123-I hippuran
348 90-150 for 99mTc MAG3 or EC
349 120-180 for 99mTc DTPA
350 There are two models equally accurate,of equivalent accuracy; the slope method with the Patlak-
351 Rutland (Rutland, 1983) plot and the integral method. (Gordon, 2011) A recent report suggests a
352 method using liver activity to help with the normalization but it has not yet been confirmed fully
353 (Blaufox 2016)
354
355 In the measurement of split renal function, aAttenuation correction usually is not necessary
356 providing if the distance of the left and right kidneys from the detector is approximately the same
357 so that both kidney counts are attenuated to the same extent (Prigent, 1999). If itIt is necessary to
358 correct for attenuation in the patients with ectopic or misplaced or displaced kidneys., Tthe
359 method of choice is to measure split renal function in using the geometric mean image calculated
360 pixel wise from conjugate combined posterior and anterior views, using for the scan a two head
361 gamma camera for the scan (Delpassand, 2000)
362
363 Total (absolute) renal function (In Vitro methods)
364 Total renal function may be performed with renal scintigraphy to obtain quantitative functional
365 data. The measurement of absolute renal function (GFR and ERPF) using radionuclides is a
366 unique technique to assess renal function, especially in patients with unilateral renal
367 abnormalities, and can be made using radiopharmaceuticals with corresponding excretion way. .
368 This is a non-invasive and accurate methodology (Blaufox 1996). Several methods have been
369 introduced for this purpose (Schlegel, 1976, Tauxe, 1982, Gates, 1982, Bubeck, 1987, Taylor,
370 1995, Itoh, 2003),; according to the radiopharmaceutical injected, using different ways to
371 evaluate injected activity and plasma disappearance or renal uptakethe timing of the blood Formatted: Font color: Auto
372 samples depends on the radiopharmaceutical injected. To ensure a correct evaluation of GFR and
373 renal function, 1-minute static imaging acquisition of the syringe with the dose to be injected is
374 performed. The same 1-minute static imaging acquisition is performed of the empty syringe that
375 must be conserved after patient injection. Linearity of the activity / counting ratio must be
376 ensured, if necessary using shielding with a known attenuation factor. If extravasation is
377 suspected, injection point must be counted with the parameters below. Well counter connected
378 with gamma camera workstation may be used instead of gamma camera acquisition of full and
379 empty syringe.
380
381 Most methods for the measurement of total renal function rely upon regression formulas. They Formatted: Paragrafo elenco1
382 are derived from a sum of renal counts in posterior projection accumulated over uptake interval,
383 corrected for radioactive decay, background, attenuation and scatter, and related to plasma
384 clearance of a radiopharmaceutical assessed from several blood samples withdrawn over
385 extended period of time. Regression methods should be applied exactly as it is recommended in
386 their original description otherwise the regression equations are invalid. Accuracy of the
387 regression methods can be affected by differences between patient population in a specific
388 department and the group of patients examined to obtain regression equations. Therefore
389 multicenter studies and independent validation of the regression techniques are required but they
390 are still mostly missing. Reports on regression methods usually do not specify proper prediction
391 errors.
392 Due to these limitations, some authors decline to measure total renal function in renal
393 scintigraphy at all, and recommend using only plasma clearance techniques based on blood
394 sampling for the purpose [Gordon 2011]. Individual kidney function is then obtained from total
395 renal function measured by plasma (or urinary) clearance using split renal function measured by
396 scintigraphy. Providing the measurement of plasma clearance and renal scintigraphy are
397 performed with two different tracers (one filtered and one secreted), it should be noted that,
398 under pathological conditions, filtration fraction may not be the same in both kidneys [Prigent
399 1999].
400 Up to our knowledge, the only regression method that have been validated in several
401 departments and reported to provide good results was developed by Taylor et al [Taylor 1995,
402 1997, Bocher 2001, Esteves 2006a, 2006b, Samal 2011].
403
404 Interpretation
405
406 Interpretation of the scan is highly dependent on s can be affected by the radiopharmaceutical
407 used for imaging. The radiopharmaceutical that is most frequently used at present is Tc-99m
408 MAG3 (mercaptoacetyltriglycine). Tc-99m DTPA (diethyl-triamino-pentaacetic acid) is used
409 less frequently. can be in most situations for the same indications but the images are not as good
410 and there is greater background. This disadvantage is offset to some degree by the lower
411 associated radiation dose. The extraction of Tc-99m DTPA delivered to the glomerulus is nearly
412 complete and its renal clearance of Tc-99m DTPA describes approximates the glomerular
413 filtration rate (GFR), and can be considered the best radiopharmaceutical for differentiation
414 between acute transplant rejection and ATN is Tc-99m DTPA since it provides better separation
415 between the vascular (perfusion) and tubular phases of tracer transport.. The vascular
416 (perfusion)first phase phase provides a qualitative assessment of renal blood flow to the kidneys
417 and helps assesswhen administered in a higher dose helps evaluate vascular compromise and to
418 differentiate ATN from acute transplant rejection. Relatively preserved perfusion at with reduced
419 function is also seen in acute contrast nephropathy.
420 Tc-99m MAG3 has significantis bound by plasma protein binding significantly so that its
421 glomerular filtration is minimal while the effective first pass extraction fraction is about 50-60
422 %. Tc-99m MAG3 is preferred over Tc-99m DTPA for functional imaging of the kidneys
423 because of its rapid accumulation in the kidney parenchymatubules and effective excretion
424 through the collecting system.. A 3 fold excretion results in better display of functional renal
425 parenchyma and more efficient assessment of urinary tract patency. Although it is less suited to
426 differentiate preserved perfusion from function in ATN because of the radiation associated with
427 a high dose, it is more effective in detecting renal outflow obstruction, renal transplant
428 dysfunction, renal trauma and posttraumatic or iatrogenic urinary leaks.
429 Nephrotoxic drugs can prolong parenchymal radiotracer transit and depending on the severity of
430 toxicity damage and also result in reduced parenchymal uptake. Nephrotoxic drugs include
431 cyclosporine, aminoglycosides and cytotoxic chemotherapy drugs. Most cytotoxic drugs cause
432 tubulo-interstitial injury: carboplatin, cetuximab, cyclophsophamide, ifosmamide, interferons,
433 methotrexate, pantumumab, streptozocin. Others affect the vasculature and renal perfusion:
434 bevacizumab, gemcitabine, interleukin 2, mitomycin C, nitrosoureas, sorafenib, sunitinib.
435 Space occupying lesions can be detected by functional imaging as parenchymal defects.
436 Ultrasound, CT and MR imaging are best suited for evaluation of space occupying lesions and
437 should be recommended when regional defects in parenchymal function are detected. Functional
438 imaging may play a role before surgical interventions to assess residual renal function after
439 partial or complete unilateral nephrectomy.
440 Pseudo- tumors of the kidneys are non-malignant masses that can mimic renal tumors. They can
441 have a developmental etiology with normal parenchymal function such as persistent fetal
442 lobulation, dromedary hump, or prominent columns of Bertin. Infectious / inflammatory diseases
443 will result in reduced parenchymal function. Infectious diseases with renal cortical defects on the
444 scan include focal pyelonephritis, renal abscess, and post pyelonephritic scarring. Examples of
445 inflammatory diseases with focally or regionally decreased parenchymal function are
446 xanthogranulomatous pyelonephritis and sarcoidosis. Other examples of renal pseudo tumors
447 with decreased parenchymal function are arteriovenous malformations, hematomas and
448 extramedullary hematopoiesis.
449 While in the past radionuclide imaging was used extensively for differentiation of ATN from
450 acute rejection, today it is mostly used for diagnosis of surgical complications such as urinary
451 leakage, renal artery stenosis, or obstruction. Another important cause of urinoma is renal
452 trauma. While CT, US or MRI provide exquisite details of the anatomical changes, scintigraphy
453 can help assess regional kidney function and rule out urine leakage. SPECT/CT at the end of a
454 functional study will provides localization of an urinoma.
455
456 SPECIAL CONSIDERATIONS FOR CHILDREN
457 See Pediatric guidelines
458 VII. DOCUMENTATION AND REPORTING
459 The report should contain the essential elements required to evaluate and interpret the study and
460 aims to communicate the results to the referring physician in a clear and concise manner
461 designed to optimize patient care (1-5).
462 I - Study identification
463
464 a. Patient name and surname, and medical record number or patient code, if appropriate
465 b. Age or date of birth and gender.
466 c. Date of study (and time of different acquisitions if relevant).
467 d. Type of renal test such as radionuclide renography (and eventually either diuresis
468 renography or captopril renography if applicable), renal cortical scintigraphy
469 (eventually renal cortical SPECT) or evaluation of renal allograft.
470 d.e. Administered dose and identity of radiopharmaceutical
471
472 II Clinical information
473
474 a. Indication:
475 The reason for referral is the justification for performing the study and should indicate the
476 clinical question the study is designed to answer
477 b. Other relevant history
478 b-1. State the most recent serum creatinine values and date. Otherwise state there is no
479 recent creatinine available.
480 b-2. When the renography is performed using either furosemide or captopril, list current
481 medications especially those which may disturb renal hemodynamics and renal transit time (such
482 as diuretic, angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker, calcium
483 blocker, non-steroidal anti-inflammatory drug) and interfere in the test interpretation). Similarly
484 indicate a sodium dietary restriction.
485 b-3. Summarize relevant results of recent nephrourologic imaging procedures (CT, US,
486 MRI, etc.) or radionuclide renal test, and date of procedure.
487 b-4. Summarize any relevant urological procedures (pyeloplasty, stent placement or
488 removal, percutaneous nephrostomy, lithotripsy) and date of procedure.
489
490 III Procedure description
491
a.
492 Specify any additional hydration in the department (oral, intravenous, type of hydration, volume
493 and timing relative to tracer injection).
494 a. Radiopharmaceutical
495 State the name of radiopharmaceutical and type of tracer:
496 Glomerular filtration tracer, Formatted: Font: Bold
497 99mTc- diethylenetriaminepentaacetic acid (DTPA)
498 Tubular secretion tracer, Formatted: Font: Bold
499 99mTc mercaptoacetyltriglycine (mertiatide) (MAG3),
500 99mTc L,L - ethylenedicysteine (EC),
501 131I- or 123I- orthoiodohippurate (OIH), (not in general use)
502 99mTc-(CO3) tricarbonylnitriloacetic acid (NTA, not commercially available.) Formatted: Font: Bold

503

504

505 retention Retention tracer, Formatted: Font: Bold, French (France)

506 99mTc-dimercaptosuccinic acid (DMSA) Formatted: Font: Bold, French (France)
507 Glomerular filtration and cortical retention tracer, 99mTc-glucoheptonate (GH) Formatted: French (France)
508
c. Indicate administered activity (dose) in MBq and . Consider :estimation of the effective dose
509 as expressed in mSv. Theand the equivalence in terms of percentage of the yearly natural
510 radiation or effective dose of thorax-abdomen-pelvis CT is recommended.
d.
511 Indicate the route of administration and, eventually, the poor qualityand quality of the IV bolus
512 injection. with extravasation.
e.
513 Indicate other drugs used, such as furosemide (see guideline on obstructive uropathy) or
514 captopril (see guideline on renovascular hypertension). Indicate name, dose, route of
515 administration, and delay (min) between radiopharmaceutical administration and image
516 acquisition (e.g., F-15, F0, F+20, captopril + 60, ).
f.
517 Indicate whether the patient could have voided immediately before the image acquisition or not
518 (especially for renography).
519 Indicate the patient position during acquisition (e.g., supine)
h.
520 Indicate the timing of image acquisition relative to the radiopharmaceutical administration
521 (especially for renal cortical imaging).
522 Describe the imaging procedure
523 Dynamic acquisition: number of stages (e.g., vascular, renal, furosemide post-injection, post-
524 micturition,), frame time (in seconds), duration (in minutes), and incidence views (e.g.,
525 posterior for renography, anterior for transplant evaluation).
526 Post void acquisition after an upright posture for a few minutes (diuresis renography).
527 Image the injection site if either a camera-based clearance or a quantitative kidney uptake (as
528 expressed in percentage of the injected activity) measurement if performed.
529 Static acquisition: delay between DMSA injection and image acquisition, and either frame time
530 and incidences positions (e.g., posterior and obliques) or SPECT.
j.
531 Measure the voided volume and note the time of voiding to estimate the urine flow rate (diuresis
532 or captopril renography).
k.
533 Indicate any side effect or complication (e.g., flank pain during diuresis renography or blood
534 pressure drop after captopril,) and related treatment.
535 Processing:
536 State Describe background and renal (whole-kidney) regions of interest (ROIs) and method of
537 relative renal uptake measurement and transit/drainage parameter calculation.
538 State Describe additional ROIs (e.g., parenchymal, pelvic) and other quantitative parameters of
539 uptake and transit/drainage.
540 Description of findings
541 Indicate the quality of the study (e.g., dose extravasation, patient motion,..)
542 State the configuration of the kidneys (i.e., sizes, shapes, locations, defects, symmetry)
543 Renography
544 Describe the image series (e.g., symmetrical and prompt uptake, rapid excretion, no significant
545 retention in the collecting system) and, if abnormal, renograms (e.g., vascular first-pass
546 pattern, plateauing curve,)
547 Specify quantitative parameters
548 Relative uptake of the right and left kidneys, expressed as percentages of the total uptake and the
549 normal range.
550 Transit parameters of transit/drainage and their normal ranges
551 Voided volume, urine flow rate and residual urine volume, when appropriate
552 Cortical renal imaging
553 Describe the shapes, contours, uptake homogeneity, column de Bertin visualization,
554 Specify the relative uptake of the right and left kidneys, expressed as percentages of the total
555 uptake and the normal range.
556 Impression and result display on hard copies
557 Name of the patient, date of birth and date of the test
558 Radiopharmaceutical and diuresis or captopril renography when appropriate
559 Relative renal function as expressed in percentages and normal range
560 Transit parameters (one or two at the most) with their normal ranges
561 A short series of summed images representative of the different phases of the renography. Gray
562 or color scale can be used. For cortical renal imaging using film rather paper print is
563 recommended.
564 Labelled ROIs on a summed image
565 Right and left background-corrected renograms, identified by color or line structure, displayed
566 on the same diagram. The renogram curves should express in counts/sec and scaled on the y-axis
567 on the higher peak count.
568
569 Comments and conclusion
570 Indicate any study limitation, patient symptom or side-effect
571 Recall the indication and specific clinical question
572 State in an as clear (e.g., avoid consistent with) and concise a statement as possible either
573 the suspected diagnosis or the answer to the asked questionindication for the test.
574
575 Differential diagnosis, if appropriate
576 Recommendations for further diagnostic procedures, if appropriate
577 Name and reference of the nuclear medicine physician responsible of the test.
578
579 Requesting physician, and other health care providers such as the primary care physician, if
580 appropriate
581
582
583 VIII. EQUIPMENT SPECIFICATIONS
584
585
586 IX QUALITY CONTROL AND IMPROVEMENT
587 Before processing, image data of dynamic renal scintigraphy should be first checked for
588 sufficient number of counts (signal-to-noise ratio), extravasation, appearance of activity in the
589 heart, position of the patient and of examined organs in the field of view and for motion. A
590 simple means for the quality control is to run the study in a cine mode. Patient movement, renal
591 uptake of the tracer, transit from parenchyma to pelvis as well as drainage of the collecting
592 systems is thus easily noted [Gordon 2011].
593
594 Visual assessment of the images can be completed by simple aids. It is assumed that in a normal
595 kidney, a peak renal count rate after background subtraction of approximately 200-250 cps will
596 result in a renogram requiring no or little smoothing prior to interpretation and estimation of
597 relative function [Cosgriff 1992, Prigent 1999]. For time-activity curves from the kidney and
598 background ROIs, a formula for the number n of passes of a (1-2-1) filter, subject to a minimum
599 of two, has been recommended by Fleming [Fleming 2006]
600 Required number of counts also depends on type of analysis to be done. More sophisticated
601 methods may need faster frame rate and higher number of counts than qualitative assessment of
602 the study or simple measurement of relative renal function. Flow (perfusion) study requires
603 higher injected activity to reach sufficient number of counts in the images recorded with the fast
604 frame rate. Improving sensitivity of modern gamma cameras allows for sufficient number of
605 counts to be achieved with lower administered activity. However, quantitative studies to derive
606 new minimum activity levels in both children and adults remain to be done.
607
608 Some quantitative methods require specifying time zero from which other time intervals can be
609 measured. Of several alternatives, most authors recommend to use peak time of the heart ROI
610 curve because some analytical methods assume monotonously decreasing (input) heart curve.
611 The peak of the heart ROI curve thus should be visible on the curve to make sure that data
612 acquisition started before the peak. In other words, the raw curve should not start at its maximum Commented [MDB2]: Review this
613 in the first frame because then it is not clear whether it is the proper maximum or a point already
614 on the descending part of the curve in case the study was started too late. Before processing, the
615 images or the curve points before the peak of the heart curve should be deleted. In a similar way,
616 renal curves should start from zero or nearly zero counts. It is a cross-check in case the heart ROI
617 curve peaks in the first recorded frame.
618 Extravasation at the site of the injection may give rise to difficulties in data processing and may
619 lead to incorrect interpretation of the study as the shape of ROI curves may be deviated affected Commented [MDB3]:
620 [Gordon 2011]. Assessment of total renal function requires measurement of count rate in the
621 kidneys that is often related to injected counts and expressed as its fraction. If part of
622 administered activity is injected extravenously or it is delayed at the site of injection, the
623 measurement is inaccurate. Some authors therefore recommend scanning the injection site after
624 the study. If the count rate at the injection site exceeds 1-2 % of injected counts, calculation of
625 total renal function should be avoidedomitted.
626 Both kidneys should be at the center of the field of view that should also include both the heart
627 and the bladder wherever it is possible with respect to the size of the patient. In many adults, a
628 decision has to be made in advance what position of the field of view is preferred for a diagnosis
629 in a specific patient, whether one including the heart or one including the urinary bladder.
630 Motion can be detected either visually (checking that the kidneys remain within the renal ROIs
631 during the first few minutes after injection) or using special software. Small motion can be
632 usually well corrected by motion-correction software or simply compensated by drawing kidney
633 ROIs large enough to encompass the motion [Cosgriff 1992, Prigent 1999]. Large and complex
634 motion of the patient, motion of the kidneys due to deep breathing and other physiological
635 movements, often of different size and direction on the left and right sides, and especially an
636 intra-frame motion are difficult or impossible to correct properly with the tools routinely
637 available. Therefore considerable effort should be made to avoid motion during data acquisition.
638 Clear explanation of the procedure to adult patients and vacuum cushions or similar gentle
639 immobilization aids for small children is often sufficient to avoid motion so that neither sedation
640 nor anesthesia is usually required. In cases of extreme motion, it may be necessary to repeat the
641 study.
642
643 Most frequent errors
644
645 - patient is fasting before examination
646 - patient is not sufficiently hydrated before examination
647 - urinary bladder is not voided emptied before examination
648 - injected activity is not measured and recorded
649 - injected activity is too low or too high
650 - part of injected activity is administered extravenously
651 - weight and height of the patient is not measured and recorded
652 - times of activity measurement, injection, and start of the study are not recorded
653 - the heart / urinary bladder (depending on the purpose of the study) are outside the field of view
654 - motion of the patient is not prevented
655 - motion of the patient is not recognized and corrected
656 - data acquisition is started too late so that the peak of the heart ROI curve is missed
657 - frame intervals in the uptake phase are too long (> 10 s)
658 - the heart ROI is too looselarge
659 - the kidney ROIs are too loose large or too tightsmall
660 - background ROIs include part of the kidney, renal pelvis or the ureters
661 - some values of the kidney ROI curve after background subtraction are negative
662 - specified uptake interval starts too early
663 - specified uptake interval ends too late
664 - specified uptake interval includes the peak of the kidney curve
665 - optimal position of uptake interval is not checked with both kidney curves
666 - background counts are not subtracted
667 - subtraction of vascular background is neglected or not performed properly
668 - measurement of split renal function and other indices is performed only once
669 - number of measurements, arithmetic mean value and its variance are not reported
670 - conjugate (posterior and anterior) views are not checked for registration
671 - geometric mean of conjugate views is not calculated pixel wise but with the kidney ROI sumsis
672 improperly calculated
673 - posterior view is not corrected for table attenuation
674 - post-erect post-voiding images after dynamic renal study are not recorded
675
676 Image data should be checked for
677
678 - sufficient number of counts
679 - extravasation
680 - appearance of activity in the heart ROI
681 - position of the patient
682 - position of the examined organs in the FOV
683 - motion
684
685 Items to be especially considered in the measurement of kidney counts
686
687 - definition of uptake interval
688 - definition of ROIs
689 - background subtraction
690 - attenuation correction
691 - scatter correction
692 X. SAFETY CONFECTION CONTROL AND PATIENT EDUCATIONS CONCERNS
693
 694 XI. RADIATION SAFETY IN IMAGING
695 An SNM guideline on dosimetry is being developed. When approved and available this guideline
696 will supersede the radiation dosimetry tables in individual guidelines. Approval for each
697 guideline should be obtained from the EANM Dosimetry Committee during the guideline writing
698 process. The values for the radiation dosimetry tables are usually readily available from the SNM
699 MIRD committee, ICRP 54 and it addenda. The estimated radation doses for the procedures and
700 agents discussed in this guideline are shown in the tables below:
701 Table 1.
Radiation Dosimetry in Adults Formatted Table

Administered activities Largest radiation dose Effective dose

MBq MBq mCi mCi
Radiopharmaceutical min max min max Organ mGy/MBq rad/mCi mSv/MBq Formatted Table
rem/mCi
51 *
Cr EDTA 3.7 - 3.7 0.1 - 0.1 Bladder 0.024 0.0895 0.0020 0.008
123
I hippuran 3.7 - 14.8 0.1 - 0.4 Bladder 0.19 0.71 0.0120 0.045
131
I hippuran 1.295 - 1.295 0.035 - 0.035 Bladder 0.92 3.43 0.0520 0.196
99m
Tc DMSA* 74 - 222 2.0 - 6.0 Kidney 0.18 0.67 0.0088 0.033
99m
Tc DTPA* 185 - 370 5.0 - 10.0 Bladder 0.062 0.23 0.0049 0.018
99m
Tc EC* 185 - 370 5.0 - 10.0 Bladder 0.095 0.35 0.0063 0.024
99m
Tc
glucoheptonate# 370 - 555 10.0 - 15.0 Bladder 0.056 0.21 0.0090 0.034
99m
Tc MAG3* 185 - 370 5.0 - 10.0 Bladder 0.11 0.41 0.0070 0.026
*
Data are from (ICRP Publication 106. Radiation Dose to Patients from Radiopharmaceuticals - Addendum 3 to ICRP
Publication 53. Ann. ICRP 38 (1-2), 2008)

Data are from (ICRP Publication 80. Radiation Dose to Patients from Radiopharmaceuticals (Addendum to ICRP
Publication 53) Ann. ICRP 28 (3), 1998)
#
Data are from (Radiation Dose to Patients from Radiopharmaceuticals ICRP
Publication 53 Ann. ICRP 18 (1-4), 1988.)

702
703
704 Table 2.
705
Dose to the fetus per unit activity administered to the mother
(mGy/MBq)
Early 3 months 6 months 9 months
51
Cr EDTA* 3.4x10-3 2.6x10-3 1.3x10-3 1.2x10-3
123
I Hippuran 3.1x10-2 2.4x10-2 8.4x10-3 7.9x10-3
131
I Hippuran 6.4x10-2 5.0x10-2 1.9x10-2 1.8x10-2
99m -3 -3 -3
Tc DMSA 5.1x10 4.7x10 4.0x10 3.4x10-3
99m
Tc DTPA 1.2x10-2 8.7x10-3 4.1x10-3 4.7x10-3
-2 -3 -3
99m
Tc EC* 1.3x10 9.7x10 4.0x10 3.8x10-3
 99m
Tc Glucoheptonate 1.2x10-2 1.1x10-2 5.3x10-3 4.6x10-3
99m
Tc MAG3 1.8x10-2 1.4x10-2 5.5x10-3 5.2x10-3

*
No published data. Personal Communication, M Stabin, 2017

Russell JR and Stabin MG, Sparks RB and Watson EE. Radiation Absorbed Dose to the
Embryo/Fetus from Radiopharmaceuticals. Health Phys 1997; 73(5):756-769
706
707
708 XII. ACKNOWLEDGMENTS
709 The authors acknowledge the members of the EANM (Name) Committee, of the European
710 Society of (Name), of the EANM Executive Committee, and of the SNMMI Committee on
711 Guidelines for their contributions to this manuscript.
712 The Committee on SNMMI Guidelines consists of the following individuals:
713 Kevin J. Donohoe, MD (Chair) (Beth Israel Deaconess Medical Center, Boston, MA); Sue
714 Abreu, MD (Sue Abreu Consulting, Nichols Hills, OK);Helena Balon, MD (Beaumont Health
715 System, Royal Oak, MI); Twyla Bartel, DO (UAMS, Little Rock, AR); Paul E. Christian,
716 CNMT, BS, PET (Huntsman Cancer Institute, University of Utah, Salt Lake City, UT);
717 Dominique Delbeke, MD (Vanderbilt University Medical Center, Nashville, TN);
718 VaskenDilsizian, MD (University of Maryland Medical Center, Baltimore, MD); Kent Friedman,
719 MD (NYU School of Medicine, New York, NY); James R. Galt, PhD (Emory University
720 Hospital, Atlanta, GA); Jay A. Harolds, MD (OUHSC-Department of Radiological Science,
721 Edmond, OK); Aaron Jessop, MD (UT MD Anderson Cancer Center, Houston, TX); David H.
722 Lewis, MD (Harborview Medical Center, Seattle, WA); J. Anthony Parker, MD, PhD (Beth
723 Israel Deaconess Medical Center, Boston, MA); James A. Ponto, RPh, BCNP (University of
724 Iowa, Iowa City, IA); Lynne T. Roy, CNMT (Cedars/Sinai Medical Center, Los Angeles, CA);
725 Schoder, MD (Memorial Sloan-Kettering Cancer Center, New York, NY); Barry L. Shulkin,
726 MD, MBA (St. Jude Childrens Research Hospital, Memphis, TN); Michael G. Stabin, PhD
727 (Vanderbilt University, Nashville, TN); Mark Tulchinsky, MD (Milton S. Hershey Med Center,
728 Hershey, PA)
729 The EANM Executive Committee consists of the following individuals:
730 Fred Verzijlbergen, MD, PhD (Erasmus MC Centreal Location, Rotterdam, Netherlands); Arturo
731 Chiti, MD (IstitutoClinicoHumanitas, RozzanoMi, Italy); SavvasFrangos, MD (Bank of Cyprus
732
733 XIII. APPROVAL
734
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