Os214 1 #2b Rft Renal Imaging 40b

Renal Function Tests: Renal Imaging

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EXCRETORY

BLOCK B

Trans 2B | Exam 1

Dr. Lynn Gomez OUTLINE I. Types of Renal Imaging A. Plain KUB B. Intravenous Pyelogram C. Retrograde Pyelography D. Ultrasound E. Radionucleide Studies F. Other Tests II. Additional Notes

OS 214

so check first for kidney function before doing IVP (<1.4) fairly accurate procedure when properly done at 30 minutes maximum visualization of Kidney parenchyma

Paul and Jung:

quotable quote:

*** classmates. sorry but we were not able to obtain a copy of dr. gomez’s powerpoint. So, ayun, tagpi-tagpi nalang itong aming additional trans (lecnotes, booknotes, and internet). hope this would suffice.***

also known as do excretory urography “if you not know, do not touch.” or intravenous urography -- the modern interpretation of primum non nocere requires intravenous injection of radiopaque contrast mat serial films are then obtained over 15 to 25 minutes as the

visualization of the renal collecting systems, ureters, and blad

I

Types of Renal Imaging A. Plain KUB

 Has little specific information

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from Paul and Jung patient in a supine position Includes the kidneys and the ureteral and bladder areas. Must be obtained before contrast medium is given for EXU Renal shadow and Psoas muscle shadow are seen along with radiopaque calculi, ureters are not Shadow of bladder, vesical calculi, phleboliths, arterial plaques can be seen INFO: size, shape, and position of the kidneys, presence of calcium in cysts, tumors, or stones can be detected along with vascular or lymph node calcifications in the area

B. IntraVenous Pyelogram (IVP)

patient preparation before an elective examination often i

such as castor oil, senna preparations (X-Prep), or bisacodyl (D

The contrast media are organic iodides that depend on the

are two types of contrast material in use: ionic and nonionic. T iothalamate-based media, has been standard for more than 4  Contraindications to injection of intravenous contrast ma (1) hypersensitivity to the contrast agent (2) presence of combined renal and hepatic disease (3) oliguria (4) a serum creatinine level higher than 2.5 to 3.0 mg/100 m (5) Insulin-Dependent Diabetes Mellitus (IDDM) in combinat greater than 1.5 mg/dL) (6) multiple myeloma (unless the patient can be kept well h (7) history of severe allergy (8) use of the oral hypoglycemic agent metformin (Glucoph  Patients who are using metformin are at risk for severe lact high mortality - approximately 50% it is recommended to stop metformin for 48 hours before emergency studies should be weighed on a case-by-case hours before the patient is restarted on the drug.  Contraindications are relative: value of potential informatio risk in each patient

 More information with Intravenous pyelogram (a 

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dye is injected) 2 Phases: pyelogram and nephrogram phase 1) Nephrogram - blood opacification of tubal parenchyma - depends on GFR, dose, and rate (if with  GFR, it may add more injury and is nonvisualizable 2) Pyelogram - filling of pelvocalyceal system - length of ureter is around 11 cm, but the Left is longer than the Right by 1.5 cm Information obtained from IVP Renal size, position, number Possible calcification, distortion, intrusion, extrinsic mass Adequacy of parenchymal thickness, abnormality of cortical contour or papillary appendage Dilation or blinding of calyces, abnormal position of kidney, reflex course of ureters, variations

FIGURE 1: The KIDS. A. Two kids blowing through a straw in a balloon is analogous to the urinary system.B. Pebble obstructing a straw is analogous to a stone obstructing a ureter. C. One kid not blowing into a straw is analogous to a non-functioning kidney. D. An absent kid is analogous to an absent kidney.

Clinical Radiology MRS: Analogy for IVP  caution however in using IVP when GFR is already low since the kidney is already nonvisualizing

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Renal Function Tests: Renal Imaging Dr. Lynn Gomez

OS 214

EXCRETORY

BLOCK B

Trans 2B | Exam 1

pyelolymphatic backflow (upper arrow). University Of Minessota Website: Pyelotubular backflow is outlined (lower arrow).  uses multiple radiographs at a particular sequence -showing contrast enhancement of the renal There is also some extravasation in the vicinity of vasculature (vascular phase), renal parenchyma (nephrogram phase), renal collecting system, the ureteropelvic junction, representing interstitial and ureters (pyelogram phase) backflow.  Indications for an IVU Evaluate the size, shape, and position of the kidneys, ureters, and bladder. D. Ultrasound Investigate the cause and source of hematuria, pyuria, dysuria, suspected calculi or masses, and urinary incontinence.

 One of the best diagnostic tests because it is

non-invasive and does not depend on the GFR or kidney but it is very operator dependent  If kidney length is <9cm, it is abnormal  If difference in length of two kidneys is >1.5cm, Determine the effect of retroperitoneal or intraabdominal massesofon the structure, indicative asymmetric renalposition, disease and

function of the urinary tract Evaluate the result of trauma to the urinary tract. Normal renal Qualitative assessment of renal function and patency of the urinary tract. anatomy. Postoperative assessment of the urinary tract. Longitudinal  Contraindications: ultrasound of Anuria (absence of urine production) right kidney in which the Severe dehydration Severe uremia – expectant poor contrast opacification of the urinary tract as a echogenic result of central renal decreased glomerular filtration. sinus is visible. Prior contrast reaction. The renal parenchyma is Intravenous isoechoic or hypoechoic to adjacent normal liver. urogram of a (Courtesy of Deborah Krueger, RDMS.) normal person showing good filling of the  Simple Cysts - no internal echoes with sharply pelves, calyces, and ureters defined smooth lining down to about the level of the compression The claw sign device, the of a renal cyst superior portion of which overlies the lower fourth (arrows). lumbar vertebra.

C. Retrograde Pyelography  Injection of dye by placement of catheter through urethra by cytoscopy to renal pelvis  Done if you cannot perform IVP Nephrotomogram clearly outlines the smooth wall of the radiolucent cyst adjacent to the density of Paul And Jung the opacified parenchyma.  generally used when the EXU has been unsatisfactory or inconclusive for visualization of the renal collecting system and ureters  Hydronephrosis—multilobulated fluid collection  cystoscopy and catheterization of the ureters are necessary for this examination  roentgenograms are obtained after direct instillation of contrast material (3 to 5 ml, intravenouswithin contrast renal agent diluted to 20%-30%) into the pelves through the catheters system  catheters are withdrawn, and another roentgenogram is obtained  oblique views and delayed frontal views also may be necessary in some patients  contrast medium may be injected by syringe or introduced by gravity with the vessel Minimal containing the bilateral medium no higher than 45 cm above renal level.

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care should be taken to avoid overdistention of the collecting system, because the high pressure may produce backflow into the renal tubules, interstitium, lymphatics, or veins

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chief advantage of retrograde pyelography: contrast material can be injected directly under controlled pressure into the ureters and collecting system; if performed correctly, provides unsurpassed visualization of the ureter and collecting system in patients whose renal function is impaired hydronephrosis. The pelves are not enlarged, but there is a little blunting of the calyces. Note the Backflow. This minimal pyelolymphatic backflow on the right retrograde (arrow). pyelogram shows a marked amount of

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Renal Function Tests: Renal Imaging Dr. Lynn Gomez Bilateral hydronephrosis showing the value of delayed films. A: Intravenous urogram, obtained 15 minutes after injection of a contrast agent, shows dilatation of pelves and calyces with no definite ureteral opacification. B: This film, exposed 90 minutes after injection of the medium, shows dilatation of ureters extending down to stricturelike narrowing, which is a little higher on the right than on the left.

E. Radionucleide Studies  very informative but expensive 1) 99mTc 2) DTPA—Diethylenetriaminepentaacetic acid 3) DMSA—2,3Dimercaptosialic acid 4) 131 I 5) OIH  Indication for Nuclear Perfusion 1) Quantify total renal function (overall GFR and RPF) 2) Quantify the percentage contribution of each overall renal function 3) Detect obstruction 4) Detect (+) / (-) of normal renal parenchyma in suspecting mass lesion 5) Evaluate renovascular disease Normal renal anatomy. Coronal T1weighted magnetic resonance image. Multiplanar capability allows wide range of

OS 214

EXCRETORY

BLOCK B

Trans 2B | Exam 1

Multiplanar capability allows wide range of imaging planes

 Computerized Tomography (CT) - preenhanced  LT Renal angiography  Screening aortography  MRA and Contrast Angiography - parang pinipicturan ang loob ng pasyente  Arteriography or Venography

II

Additional Notes Cystatin C

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a nonglycosylated protein that belongs to the cysteine protease inhibitors, cystatin superfamily - play an important role in the regulation of proteolytic damage to the cysteine proteases

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produced at a constant rate by nucleated cells

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found in relatively high concentrations in many body fluids, especially in the seminal fluid, cerebrospinal fluid and synovial fluid low molecular weight (13.3 kDa) and positive charge at physiological pH levels facilitate its glomerular filtration

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reabsorbed and almost completely catabolized in the proximal renal tubule  because of its constant rate of production, its serum concentration is determined by imaging planes glomerular filtration levels of cystatin C are independent of weight and height, muscle mass, age (over a year of age), and sex its concentration is not influenced by Doctor’s Advice infections, liver diseases, or inflammatory  If 2 Kidneys are obstructed: operate on the more obstructeddiseases Kidney (less GFR).

 If you want to donate a Kidney, keep the Kidney with the higher GFR measurements can be made and interpreted from a single random sample.

F. Other Tests

 Magnetic Resonance Imaging (MRI) superior to CT Scan in ability to detect tumor thrombus (in major vessels in distinguishing renal hilar collecting vessels), adrenal mass lesions, pheochromocytoma Normal renal anatomy. Coronal T1weighted magnetic resonance image.

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use of serum cystatin C as a marker of GFR is well documented, and some authors have suggested that it may be more accurate than serum creatinine for this purpose.

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blood level of cystatin C predicts survival after one type of heart attack - a high level of cystatin C level in the blood after a heart attack is an ominous sign because it reflects the failure of the kidney to clear cystatin C from the blood into the urine

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mutation of the cystatin C gene is responsible for a type of amyloidosis in which deposits in the brain result in premature strokes, intracranial hemorrhage, and dementia. This disease is called amyloidosis VI or cerebroarterial amyloidosis. It is inherited in an autosomal dominant manner.

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Renal Function Tests: Renal Imaging Dr. Lynn Gomez

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OS 214

EXCRETORY

BLOCK B

Trans 2B | Exam 1

Cystatin C has nothing to do with the statin drugs that are used to lower cholesterol. Cystatin C is also known as cystatin 3 and CST3.

Age Premature 2-8 days 4-28 days 35-95 days 1-5.0 months 6-11.9 months 12-19 months 2-12 years Adult Male Adult Female TABLE 1: Normal at Different Ages

GFR (ml/min/1.73m2) Mean Range (2SD) 47 29-65 38 26-60 48 28-68 58 30-86 77 41-103 103 49-157 127 63-191 127 89-165 131 88-174 117 87-147 Glomerular Filtration Rates (GFR)

IAIA

hello 2010. what’s up everyone? Hehe. Exag naman nitong trans na ito. May pahabol pa. Jologs kase ng Osiris download chuva eh. Willing na nga si Dr. Gomez na magbigay, pinagbawalan pa. Owel. Anyway, if ever we do obtain a copy of her lecture (with her permission, of course… panu ba naman kami makakakuha non?), we promise to release another trans. tada! Trans 2C! haha. Pasensya na talaga na ultra-mega patchwork itong trans naming. Sobrang rapid ng pagswitch ng slides ni lecturer eh Anyway, shoutouts to my superfriends!  glai, mab, leah, martin n, piws. Hehehehellooooh. And to my seatmates maqi and mia, frontmates mel r, vv, donya, martin o., mel l., jakes. And backmates jo, steph, charles and jazel… and to the occasional occupants of the aisle seat edison, kathy, and karen p. Happy birthday paching! (dec 1 pa kasi ngayon. Well, kahit hindi mo naman to agad mabasa. Happy birthday pa din!) Hello also to the AMAZING ALTOs… let’s keep on amazing people. To the UltraNega Angel. Hahaha. You’re verrrry funny!  Mere, kumusta ang ating catching up? Haha. Who else to greet? All this greeting space is mine. Of course, THE END.. Thanks so much for being very efficient, pasensioso, and responsible people. Wooohoo. Same goes to the best group ever: LASTPEOPLESTANDING! (kanino na nga ulit ito nagsstart, joguel? hehe) Galing. It’s always fun to be with you guys.  always looking forward to group stuff with you.  tuluy- tuloy ang ultra benign group sessions. Congrats nga pala sa Turnover Ceremonies! Ang galing. Tummy exercise to the max sa kakatawa. Ahahaha. Thank you Valence! Good Luck ShitHead Zham. Goodluck People sa TRP! At sa atin sa exam… oh no! boo.

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