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Radionuclide Investigations of the Urinary Tract in the Era of Multimodality Imaging^*

Ariane Boubaker^,1, John O. Prior^,1, Jean-Yves Meuwly² and Angelika Bischof-Delaloye¹

¹ Department of Nuclear Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; and ² Department of Radiodiagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

View larger version (13K): [in a new window]   FIGURE 1.  Diuretic renography (F+0) in 6-mo-old boy who had febrile UTI by age of 2 mo. Renal sonography and VCUG had normal findings. (A) One-minute posterior views demonstrate normal tracer uptake by both kidneys and rapid washout, with bladder activity visible from third minute after injection and spontaneous micturition occurring at minute 10. (B) Left (red) and right (blue) renal time–activity curves show symmetric relative function (left, 50%; right, 50%) and normal time to peak (<180 s).

View larger version (57K): [in a new window]   FIGURE 2.  Bilateral duplex kidney diagnosed in 9-y-old boy after febrile UTI. (A) VCUG shows bilateral pyeloureteral reflux with opacification of incomplete systems, suggesting duplication. (B) Coronal T2-weighted MRI scan confirms presence of duplex kidneys bilaterally. Lower pyelocaliceal systems are dilated (arrows) even when upper ones remain thin (arrowheads). (C) Sagittal sonographic view of right upper quadrant shows enlarged kidney with broad layer of parenchyma on upper pole (arrowhead) and atrophic lower pole (arrow). (D) One-minute parenchymal view shows decreased tracer uptake by left lower system and parenchymal defects at both poles of right kidney. (E) Images obtained 1, 4, 9, and 15 min (from left to right) after injection show delayed urinary flow in lower moiety of left kidney due to loss of parenchymal function. (F) Renograms of left and right kidneys show symmetric function (left, 49%; right, 51%) and no significant impairment of urinary flow under furosemide. (G) Indirect radionuclide cystography demonstrate VUR in both left and right lower systems.

View larger version (36K): [in a new window]   FIGURE 3.  Diuretic renography (F+0) obtained during follow-up of 4-y-old girl treated conservatively for left pelviureteric junction stenosis detected prenatally. (A) One-minute posterior views show dilated left kidney with preserved parenchymal function despite impaired urinary drainage above pelviureteric junction. Right kidney is normal. (B) Left (red) and right (blue) renograms confirm symmetric (left, 51%; right, 49%) and normal tracer extraction by both kidneys and abnormal urinary flow out of left kidney. (C) Images obtained 20 min after injection (left), after miction (middle), and 50 min after injection (right) show residual activity within left renal pelvis after miction and 50 min after injection. (D) Initial sonographic sagittal view of left kidney shows enlargement of pyelocaliceal system. (E) Follow-up sonogram obtained at same time as diuretic renography shows persistent enlargement, with satisfactory growth of left kidney.

View larger version (38K): [in a new window]   FIGURE 4.  25-y-old patient with chronic renal insufficiency due to reflux nephropathy. (A) CT scan shows atrophic left kidney (arrow) with dilated pelvis. (B) First-minute parenchymal image shows small scarred left kidney and also upper and lower parenchymal defects of right kidney (differential renal function: left, 31%; right, 69%). (C) Indirect radionuclide cystography shows massive left VUR. (D) VCUG shows massive left pyeloureteral reflux. (E) Sagittal sonogram shows dilatation of distal left ureter (arrow).

View larger version (41K): [in a new window]   FIGURE 5.  Stenosis related to FMD in 35-y-old man. (A) ACE inhibitor renography shows 1-min images of radiotracer uptake (99mTc-MAG3). Right kidney is performing 95% of the renal function, which was decreased (tubular extraction rate, 160 mL/min/1.73 m2). (B) Time–activity curves of left (blue) and right (red) kidneys show almost no participation of the left kidney to renal function. (C) Angiogram shows irregular stenosis (arrow) and beading (arrowheads). (D) Color Duplex sonography of peripheral artery of left kidney demonstrates parvus–tardus pattern with collapsed resistance index (0.35). (E) In contrast, right kidney shows normal Doppler spectrum.

View larger version (28K): [in a new window]   FIGURE 6.  RAS in 63-y-old man with chronic renal insufficiency (creatinine clearance, 40 mL/min) and subrenal aortic inflammatory aneurysm with right renal hydronephrosis due to ureter compression. (A) On ACE inhibitor renography with 123I-OIH, images obtained at 1, 6, 11, and 16 min (from left to right) after injection show poor function of right kidney, assuming only 10% of total renal function. (B) Time–activity renal curves were identical to baseline (not shown). (C) Coronal 3-dimensional MRA image demonstrates short stenosis on right renal artery (arrow).

View larger version (56K): [in a new window]   FIGURE 7.  RAS due to atherosclerosis in 75-y-old woman. Baseline renography with 123I-OIH (A) and ACE inhibitor renography (B) show delayed renal parenchymal uptake in right kidney, as compared with baseline (images taken at 1, 6, 11, and 16 min [from left to right] after injection). (C) Angiogram shows narrow stenosis at ostium of right renal artery (arrow). (D) Angiogram performed after angioplasty demonstrates successful dilatation of vessel (arrow). (E) Coronal 3-dimensional CT shows regular-sized reshaped vessel, with presence of stent (arrow). ACEI = ACE inhibitor.

View larger version (43K): [in a new window]   FIGURE 8.  Graft dysfunction 1 d after transplantation in 41-y-old woman. Baseline renography (A) and ACE inhibitor renography (B) show prolonged tracer transit in renal parenchyma on images and on renal and bladder curves, as compared with baseline. (C) Color duplex sonographic assessment of intrarenal vessels shows parvus–tardus pattern. (D) Color duplex sonographic exploration of renal artery demonstrates disturbance of flow. (E) Coronal 3-dimensional MRA image shows short narrowing of renal artery (arrow) at site of anastomosis. Laparotomy revealed kinking of renal artery graft. ACEI = ACE inhibitor.

View larger version (20K): [in a new window]   FIGURE 9.  Normal camera-based renography findings 5 d after transplantation of related-donor kidney: the first two 10-s perfusion images (left and middle) and the 1-min parenchymal image (right; upper pole irregularity is due to graft position) (A); whole kidney (red), cortical kidney (blue), and bladder curves (B); and sequential 1-min images (C). Somewhat prolonged visualization of ureter is due to postoperative hypotony, frequently observed during first days after transplantation.

View larger version (77K): [in a new window]   FIGURE 10.  One-minute images after injection of 99mTc-MAG3. Images were obtained 6 d after transplantation because of sudden anuria and abdominal pain. Starting with third image, irregularly shaped urinary collection suggestive of urinary leak appears (arrow). Reintervention revealed necrosis of distal ureter and confirmed urinary leak. After resection and reanastomosis of ureter, course was uneventful.

View larger version (22K): [in a new window]   FIGURE 11.  Patient with decreased graft function 5 mo after transplantation of living-donor kidney. Creatinine level was 219 µmol/L. (A) Renogram shows an 123I-OIH accumulation within normal limits, a normal peak, but delayed elimination. Normal uptake and peak are unlikely to be seen in acute rejection. (B) Corresponding 1-min images reveal tracer retention in parenchyma without outflow impairment, suggesting potential calcineurin inhibitor toxicity; normal Doppler sonography findings made RAS unlikely. Biopsy showed thrombotic microangiopathy. After change of immunosuppressive therapy from tacrolimus to sirolimus, creatinine returned to baseline level (140 µmol/L).