WELL TEMPERED RENOGRAM

PROTOCOL

Patient Preparation:
● Renal ultrasonography and VCUG prior to renography to determine if there is an
anatomic cause for HN/HUN and to determine if a megaureter is present
● Excretory urography, Percutaneous manometric antegrade pyelography to demonstrate
anatomic obstruction, loss of parenchyma or a pressure gradient with obstruction.
● Patients should be atleast 1 month of age
○ To reduce likelihood of immature renal function
○ Newborns have lower GFR than older children
○ GFR gradually increases during first 6 months of life
○ Immaturity of the kidney may reflected in the renogram - prolongation or
plateauing in the third phase
● Serum creatinine - to confirm there is no azotemia
● Oral hydration - formula or water beginning 2 hr prior to the study and throughout the
study
● IV line inserted - dilute normal saline (D5.3NS or D5.25NS at a rate to deliver 15 ml/kg
over a 30 min interval beginning 15 min prior to injection of the radiopharmaceutical.
● Infusion is continued for the remainder of the study at a maintenance fluid volume at a
rate of 200cc/kg/24hr.
● Bladder is catheterised to assure adequate drainage throughout the study.
● When HN is present either a balloon retention or straight catheter is used.
● When HUN is present a straight catheter is used in order to avoid occluding an ectopic
ureteral orifice by the balloon of the retention catheter.
● Bladder drainage during the study will reduce the absorbed radiation dose to the
bladder and gonads.
● If the bladder is not permitted to fill, patient movement due to impending urination is
avoided.
● Antibiotics for 3 days after catheterisation.
Renography technique:
● Technicium-99m-mercaptoacetyltriglycine - 50μCi/kg and a minimum dosage of 1 mCi
● Advantages of MAG3-
○ Rapid renal clearance
○ Primary excretion by the tubules upon which furosemide acts
○ In presence of obstruction or poor renal function - absorbed radiation dose is
less compared to other radiopharmaceuticals
● Patient in supine position
 ● Heart, kidneys, ureters and bladder should be within the field of view of the gamma
camera.
● Magnification is helpful in depicting renal anatomy and for determining the selection of
regions of interest (ROI).
● Digital data acquisition at 20 sce/ frame and analog images are recorded.
● Analog images - practitioner’s preference - 1 min images for 30 min, or 2 min, 5 min and
subsequent 5 min images for 30 min.
● Digital data acquired in a 128 X 128 matrix form for ease of ROI placement.
● ROI for the renogram portion of the study must encompass the entire kidney, including
the dilated renal pelvis
● ROI for background subtraction should be defined as approximately 2 pixels wide
around the outer perimeter of the ROI for the kidney.
● The renogram time-activity curve data should be acquired for a minimum of 20-30 min.
Diuresis Phase
● Diuretic pharmaceutical Furosemide is injected IV in a dose of 1mg/kg.
● Furosemide should be administered after the renogram phase (20-30 min) or when the
entire collecting system is believed to be full.
● In the presence of HN/HUN, the injection of the diuretic is delayed until the dilated renal
unit is believed to be full or is at the peak of the renogram curve if such data are
simultaneously available.
● Following the renogram portion of the study, the patient may be placed prone, or briefly
in a sitting position to help distribute the radioactivity more uniformly throughout the
entire collecting system.
● The prone position ensures that the bladder lies more dependently and thereby reduces
the likelihood of slowed ureterovesical drainage due to the bladder’s position.
● If the prone position is required to fill the entire system, then the diuretic study may be
completed in this position.
● The presence of radioactivity within the bladder is continuously monitored on the
persistence scope of the scintillation camera in order to determine if alterations in
position may augment further drainage.
● In HN, the ROI used for diuretic time-activity curve generation should include only the
renal pelvis and collecting system.
● The ROI for background subtraction during the diuretic phase should be a transcribed
semilunar area adjacent and lateral to the lower pole of the dilated collecting system.
● In HUN, a ROI is placed around the dilated pelvis and a separate ROI is circumscribed
around the ureter to the ureterovesical junction.
● Computer frame rates of 20 sec are recorded.
 ● Static images at 5 min intervals for 20 min should be adequate to image the diuretic
response.
● The combined renogram and diuretic phases of the study should take about 1 hr to
acquire the necessary data.
● In unilateral HN/HUN, the diuretic response should be compared with that of the
diuretic response of the normal, nondilated opposite kidney.
● If the diuretic response in the normal kidney is also poor, it is likely that the kidneys are
insufficiently mature to respond to furosemide and therefore reexamination at a later
date by the age of 6 months should be attempted.
Data Analysis
Percent Differential Renal Function
● The total counts of the renogram curve for each kidney minus background during the
interval between 60 sec and the appearance of radioactivity in the calyces are used to
determine differential renal function for the entire kidney.
● This measurement should correspond only to the time interval when the radionuclide
localizes in the tubules.
Percent Differential Cortical Renal Function
● Total counts from the cortical area of each kidney are also recorded in the interval
between 60 sec to initial calyceal appearance (corrected for background).
● These data are used to estimate the percent differential cortical renal function.
Twenty Minutes to Peak Ratios
● The counts obtained from the background subtracted renogram curves are used to
calculate percent 20 min/ peak ratios for the entire kidney as well as the kidney cortex
for both kidneys.
Renogram Curve Pattern Categories
● Stereotypical time - activity curve patterns for the renogram phase and the diuretic
phase are proposed for a standardized classification.
● The renogram curve patterns are categorized to suggest
○ No obstruction
○ Indeterminate
○ Obstruction
● Upward slope of the diuretic portion of the renogram curve:
○ Obstruction
○ Poor function
○ Marked HN/HUN
 ○ Poor function in a large capacity reservoir which requires further filling before
drainage occurs.
Determination of Clearance Half-time for Diuretic Response Analysis
Likelihood of Obstruction
● No obstruction
● Indeterminate
● Obstruction
● Immature renal function (diagnosis of obstruction is not yet possible by renography
● Interpretation may be confounded by :
○ State of tonicity of the pelvis or ureter
○ If dilated pelvis or ureter are atonic (prune belly syndrome)- renogram may be
consistent with obstruction even when other tests show pelvis or ureter to be
patent and therefore non obstructive
○ If dilated pelvis or ureter are hypertonic (UPJO or UVJO) the pelvis and ureter
become muscular and are able to overcome partial resistance to provide
adequate drainage, despite a luminal stenosis. The system will ultimately
decompensate.
Accuracy of Diuresis Renography
● The accuracy of diuretic renography can only be determined by comparisons against
1. The Clinical information regarding emergence of urine infection, clinical presentation
(eg failure to thrive)
2. Further impairments in renal function or increasingly impaired urine drainage on
subsequent testing
3. Surgical findings (eg stenosis)
4. Results of retesting after “successful” surgery

Radiopharmaceuticals
Tubular extraction
123
I-hippuran
99m
Tc-mercaptoacetyltriglycine
99m
Tc-ethylenedicysteine
Glomerular filtration
99m
Tc-DTPA

The tracers reflecting tubular extraction have a greater renal extraction than 99mTc-DTPA,
resulting in lower background activity and a higher kidney to background ratio.
Tubular agents are preferred for
 Estimation of DRF particularly in infants
Diuretic renography
Indirect cystography

Minimum activities recommended by the EANM are:

For a 5-year-old using 99mTc-DTPA the effective dose (ED) is 0.54–0.82 mSv, the lower figure
relating to a 1-h voiding interval.
For 99mTc-MAG3 the corresponding figures are 0.20 and 0.38 mSv, respectively, and for 123I-
hippuran 0.41and 0.7 mSv, respectively.
99mTc-DTPA and 123I-hippuran require a reduction of the injected activity if the renal function
is impaired.