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1

Introduction
The kidneys are two bean shaped organs
lying retroperitoneally on each side of
the vertebral column slightly above the
level of umblicus.
The range in length & weight,
respectively, from approximately 6cm &
24gms in a full term infant to more than
equal to 12cm & 150gms in an adult
2
NEPHRON
Each kidney contains approx.
1 million nephrons.
In humans,formation of nephron is
complete at 36-40 wks of gestation.,
but functional maturation with
tubular growth & elongation
continues during the 1st decade of life
Bcoz new nephrons cant be formed
after birth,so any disease that results
in progressive loss of nephrons can
lead to renal insufficiency.

3
Cont..

A decreased number of nephrons


secondary to LBW,prematurity &/or
unknown genetic or environmental factor
is hypothesised to be a risk factor for the
development of primary HT &
Progressive Renal Dysfunction in
adulthood.

4
Cont
A Nephron consist :-
OUTER LAYER
(the cortex)
-glomeruli
-PCT & DCT
-CD
INNER LAYER
(the medulla)
-Straight portion of tubules
-LOH
-vasa recta
-terminal CD
5
JUXTAGLOMERULAR APPARATUS
The cells of the distal tubule in
the part that comes in contact
with the afferent arterioles of
the glomerulus are more dense
than the cells in the rest of
tubule are called MACULA
DENSA
The smooth muscle cells of
afferent arterioles that
approximate macula densa
contain prominent secretory
cytoplasmic granules which are
the site of renin activity.
6
Cont

JGA is composed of the afferent


& efferent arterioles,the macula
densa & lacis cells located in the
triangular space in between
these structure.
It is involved in systemic blood
pressure regulation,electrolyte
hemeostasis &
tubuloglomerular
feedback mechanism.

7
RENAL VASCULATURE

The renal artery arising from aorta


divides into fine Segmental Arteries.
The latter divides into the Interlobar
Arteries,which branch into Arcuate
Arteries near the junction of the Cortex
& medulla.
Interlobar arteries provide the afferent
arterioles for the glomeruli.
The glomerular capillaries join to form
the efferent arteries that leaves the glomerulus & form an
extensive network of peritubular capillaries that surround the
tubules,mostly in the cortex,forming Vasa Recta.The VR along
with LOH are responsible for the urine concenteration
8
RENAL FUNCTIONS

9
DIAGNOSTIC EVALUATION

Urine Examination
-routine &
-microscopic
Evaluation of Renal Function
Renal Biopsy
Imaging

10
URINE EXAMINATION

It is the most important step for the diagnosis of renal


disease.
COLLECTION OF SAMPLE :
-the 1st morning specimen is preferred
-collected in a clean container
-for culture, the specimen should be collected in a sterile
container & sent to the lab. Immedietly, where it should be
plated within 15minutes or stored in a refrigerator at 4
degree celsius.Bacteria multiply rapidly at room
tempt., which may give false positive results.

11
Method of urine collection
Midstream urine : a clean-catch midstream specimen is
widely used. In older children who can
cooperate, midstream specimen is obtained after proper local
cleaning .The initial part of urine is discarded.
Bag collection : in neonates & infants, urine can be collected
in sterile bags. Not used for microscopic
exam.
Bladder catheterisation : a urine specimen can also be safely
obtained, in infants, by strict
bladder catheterisation but requires some skills & experience.
Suprapubic bladder aspiration : the only reliable way to
obtain reliable urine
specimen in neonates & young infants. In children <2 yrs of
age it is most suitable method for a definitive diagnosis of UTI.
12
URINE ROUTINE EXAMINATION

SPECIFIC GRAVITY : full term infants have a


limited concentrating ability with a maximum
sp.gravity of 1.021 1.025.It is measured
with clinical Hydrometer. Increase in sp.gravity
may be ass. with dehydration, diarrhea, emesis,
excessive sweating etc. while decrease in sp.gravity may be
ass. with renal failure, DI, ATN, interstitial nephritis &
excessive fluid intake.
pH : tested with pH meter. Routine lab reports of pH are of
no importnace.UTI with urea splitting organisms make urine
highly Alkaline. Normal pH ranges from 4.6 -8.0. In fasting, the
concentrated urine sample is highly Acidic .
13
Cont
-A high urine may be due to RTA(type I),UTI,Vomitng & a low
urinary pH may be due to DKA,diarrhea & starvation.

PROTEIN :
Boiling test : satisfactory but cumbersome.10-15 ml of urine
is taken in a test tube & upper portion is boiled. If turbidity
appears 3 drops of concentrated acetic acid are added &
specimen is boiled again. A zero to +4 grading is used.

14
Cont
+1 Presence of slight 30-100mg of
turbidity,through protein/dl
which print can be
read
+2 Turbidity with slight 100-300mg of
precipitates protein/dl
+3 White cloudiness 300-1000mg
with fine protein/dl
precipitate,through
which black lines
are not visible

+4 Large clumps of >1mg of protein/dl


white precipitates
15
Cont
Dipstick methods(e.g uristix) : widely used
test for Proteinuria, more convenient &
equally reliable.
-Colour changes from yellow to green.
-light chain proteins & LMW tubular
proteins are not detected by this method.
-Trace react. 5 to 20 mg/dl urinary prtn
+1 30 mg/dl
+2 100 mg/dl
+3 300 mg/dl
+4 > 1000 mg/dl

16
Cont
Proteinuria in patients with Nephrotic Syndrome is massive
(+3 or +4 by dipstick) & selective,constituted predominantly
of Albumin,without loss of proteins of higher molecular wt.
In the presence of tubular damage or physical injury to the
glomerular barrier, the proteinuria is non selective.
In renal parenchymal diseases,proteinuria is often quantified
to assess degree of glomerular injury.
Selective Proteinuria : intermediate sized(<1000kDa)
proteins(albumin,transferrin) leaks through glomerulus.
Nonselective proteinuria : range of different sized proteins
leak through,including larger proteins(immunoglobulin)

17
Cont
Quantitative Measurement of Urine Protein
-Accurate collection of urine over 24hr period is required to
quantitate protein excretion.
-A value of >4mg/m2/hr is considered abnormal, & >40/m2/hr
indicates heavy proteinuria.

-The range proteinuria in nephrotic so is massive


proteinuria(>3.5gm/24hrs)
while the range in nephritic s o is mild to moderate
proteinuria(<3gm/24hrs)

18
Cont
Urine Protein/Creatinine Ratio : an approx. estimate of the
severity of proteinuria also can be made by measurement of
urine protein & urine creatinine on random urine sample.
-Values >2 indicate Heavy Proteinuria
<0.2 are insignificant.
-Such measurements are of use in following response to
therapy in various disorders, but seldom necessary in
children with nephrotic syndrome.

19
Cont

GLUCOSE :the older methods(e.g benedict


test) that detected reducing substance have
mostly been replaced by Dipstick test,which is
based on Glucose Oxidase Peroxidase linked
reaction.
BLOOD :detection of Hb by dipstick is based on an reaction,
with a spotted +ve reaction indicating intact red blood cells &
uniform +vity suggesting presence of free Hb.However the
use of dipstick to detect hematuria is discouraged,bcoz
reactions may often be false +ve(e.g myoglobinuria,oxidising
substances,bacterial colonisation) or false ve (e.g ascorbic
acid,other reducing substances)

20
MICROSCOPIC EXAMINATION

A fresh,well mixed specimen should be examined.


Presence of cellular elements & casts should be noted.
Red cell casts : indicate glomerular inflammation.

Red cell casts & red cells in a pateint with glomerulonephritis

21
Cont
White cell casts :clumping of
neutrophils suggests
acute pyelonephritis

Epithelial cell cast :are noted in patients recovering from Acute


tubular necrosis

22
Cont

Hyaline or Fatty casts : may be +nt


in proteinuric states or in normal
in normal individuals with
concenterated urine.

Red blood cells & leukocytes can be counted under the high
power field & more accurately in a counting chamber.
>5 leukocytes/HPF along with bacteruria suggests urinary
tract infection.
Neutrophils may also be detected in proliferative
glomerulonephritis & interstitial nephritis,while the presence
of Eosinophils in urine is specific of acute interstitial nephritis23
Cont
Hematuria is defined as presence of >5RBS/HPF in a
centrifuged specimen.
RBC morphology is useful in distinguishing bet. Glomerular &
non glomerular causes of hematuria.
The site of injury is likely to be the lower urinary tract if <25%
urine correlates well with a colony count of over 105
organisms/ml indicating significant bacteriuria.

24
URINE CULTURE

Definitions of +ve or ve urine culture are dependent on the


method of collection & the patients clinical status.
Diagnosis of Urinary Tract Infection
Method of collection Colony count(per ml) Probability of infectn
Suprapubic Aspiration Any number 99%
Urethral catheterisatn >105 95%
104 to 10 5 Very likely
103 To 104 Suspicious:repeat
<103 unlikely
Midstream void
Boys >104 Very likely
Girls >105 90-95%
104 to 105 Suspicious:repeat
<104 unlikely 25
EVAULUATION OF RENAL FUNCTION

Various aspects of renal function are


-GFR(Glomerular Filtration Rate)
-RPF(Renal Plasma Flow)
-Reabsorption & Excretion of various substances like Na+, K+,
Ca+2, inorganic phosphate, glucose, urea, a.a, H2O & osmoles.
In clinical practice
-determination of Creatinine Clearance is a measure of GFR
-water deprivation & vasopressin administration tests to
determine urinary concentrating ability, &
-bicarbonate & ammonium chloride loading test to examine
urinary acidification are usually sufficient for diagnostic
evaluation & measurement of kidney function.
26
Cont
The results of these tests are important in assessing the
excretory function of the kidneys. For example, grading of
chronic renal insufficiency and dosage of drugs that are
excreted primarily via urine are based on GFR (or creatinine
clearance).

27
GLOMERULAR FUNCTION TEST
The concept of clearance is based upon the fact that the rate
of removal of a substance from the plasma must equal its
simultaneous rate of excretion in urine.
Thus if the urinary excretion rate & plasma concentration of a
substance are known, we can calculate the volume of plasma
from which that substance would have been completely
removed. INULIN has been taken as a reference substance.
The standard formula for clearance is : C = U x V
P
C = clearence/min(ml/min)
U = urinary concenteration(mg/dl)
P = plasma concenteration(mg/dl)
V = urine volume/min(ml/min)
28
Cont
If a given substance is freely filtered & neither reabsorbed nor
excreted, its clearance rate would accurately reflect GFR.
The GFR can be estimated by measuring s.creatinine level &
height.The formula proposed by SCHWARTZ is useful for
children :
GFR(ml/min/1.73m2) = K x Height(cm)
S.Creatinine(mg/dl)
K = 0.34 (in preterm infant)
= 0.45 (in term infants)
= 0.55 (in children & adoloscent girls) &
= 0.7 (in adoloscent males)

29
Cont

Serum Creatinine & Creatinine Clearance :


Creatinine is derived from the metabolism of creatine &
phosphocreatine,the bulk of which is in muscle.
Since creatinine is chiefly excreted by glomerular
filteration,S.creatinine levels reflects changes in GFR.
S.creatinine values are low when the muscle mass is
decreased, as in malnutrition.
Bilirubin interferes with creatinine measurements.

30
Cont
The normal values of S.creatinine are :
AGE RANGE(mg/dl)
Cord 0.6-1.2
Newborn 0.3-1.0
<3 years 0.17-0.35
3-5 years 0.26-0.42
5-7 years 0.29-0.48
7-9 years 0.34-0.55
9-11 years 0.35-0.64
11-13 years 0.42-0.71
13-15 years 0.46-0.81
Adult Male 0.7-1.3
Adult Female 0.6-1.1

31
Cont
CYSTATIN C : It is a LMW nonglycosylated protein produced at
a constant rate by all nucleated cells in the body, freely
filtered by the glomeruli, not secreted, but totally reabsorbed
by the renal tubules.
Little or no cystatin is excreted in urine.
Normal adults have circulating level of approx. 1mg/l.
This is better indicator of renal function as compared to
creatinine in early stages of GFR impairment as it is
independent of age,gender,body composition & muscle mass.
Cystatin C can be estimated in blood by enzyme
immunoassays or immunoturbidometry.Both techniques are
currently kit based & expensive.

32
Cont
SINGLE INJECTION TECHNIQUE : in clinical practice,
radionuclides are often used to estimate total GFR or to
measure difference in clearance bet. one kidney compared to
other in the same patient.
The technique is based on use of a single injection, plasma
disappearance curves to estimate the true GFR.
Briefly, the radionuclide dye is injected & the signal from
radiolabelled form is used to obtain measurment.
The most commonly used Radionuclides for GFR are
-DTPA (Diethyl triamine Penta-acetic acid)
-EDTA (ethylene diamine tetra acetic acid) &
-Iothalamate
Iohexol,a non ionic non radioactive LMW radiocontrast
agent,as an alternative to inulin,measured easily by HPLC(high
performance liquid chromatography)
33
Cont
BLOOD UREA : A normal level of blood urea is often
mistakenly regarded to indicate normal kidney function.
In a steady state the blood urea may not rise beyond the
upper range of normal(40mg/dl) even when 75% of the renal
function is lost.
On the other hand, prerenal factors that decreases renal
perfusion & GFR,such as dehydration,causes an increase in
blood urea levels.
There may be transient rise in blood urea level due to :
-high protein intake & excessive protein catabolism( e.g with
severe infections,tissue break down,trauma,use of large doses
of corticosteroids or tetracyclines)
-gastrointestinal bleeding & inhibition of anabolism.
34
RENAL BLOOD FLOW
Renal blood flow measurements are performed using the
clearance of PAH(para aminohippurate)
>90% PAH is extracted from the plasma during the 1st pass
through the kidneys.Therefore, renal clearance of PAH is
commonly used as an estimate of renal plasma flow(RPF).
Plasma clearance following single injection of 131I-hippuran or
99mTc-mercaptoacetyltriglycine(MAG-3)is an alternative

method.
Renal Blood Flow is calculated by dividing RPF by [1-
hematocrit].
Normal value ranges from 500 to 600 ml/min(abt.
1200ml/min/1.73m2).
Other methods-Color Doppler US,Contrast Enhanced US &
MRI. 35
URINARY CONCENTERATION
Osmolality dependes upon the number of particles in a
solution & not on their size or density.
The maximal urinary concentration capacity varies with age
- in neonates its abt. 700 mOsm/kg
- in older children & adults it an rise up to 1200mosm/kg.
Hyposthenuria(inability to increase urine osmolality > than
that of plasma) is characteristic of Diabetes Insipidus as well
as Diseases of Renal Medulla such as obstructive uropathy.
Polyuria & polydipsia are stricking features.
In chronic Renal Failure urine osmolality does not rise much
above 400mOsm/kg & polyuria & polydipsia are not
prominent.
Osmolality = 2[Na+] + [Glucose]/18 + [ BUN ]/2.8
36
Cont
URINARY CONCENTERATION TEST : Urinary concentrating
ability needs to be tested in a setting of polyuria.If the 1st
morning void after 12hrs of overnight fasting has osmolality
exceeding 700 mOsm/kg,no further testing is required.In
others, Water Deprivation Testing is done.
Response to Vasopressin : subsequently,to confirm the lack of
renal concentrating ability & distinguish Nephrogenic
Diabetes Insipidus(NDI) from Central Diabetes
Insipidus(CDI),a vasopressin test is performed.
-Desamino-8-D-arginine Vasopressin(dDAVP,desmopressin) is
administered nassly(5-10 ug in neonates & infants,20 ug in
children) or by an I.M injection(0.4-1.0 ug in infants & young
children,2 ug in older children).
The changes in urine osmolality seen are :
37
Cont

CONDITION URINE OSMOLALITY ON CHANGES IN


WATER OSMOLALITY WITH
DEPRIVATION(mOsm/kg dDAVP(mOsm/kg)
NORMAL >800-900 MINIMAL OR NO
INCREASE

COMPLETE CENTRAL DI <300 SUBSTANTIAL INCREASE

PARTIAL CENTRAL DI 300-800 INCREASE OF >10%

NEPHROGENIC DI <200-300 MINIMAL OR NO


INCREASE
PRIMARY POLYDIPSIA >500 MINIMAL OR NO
INCREASE

38
Tests Of Urinary Acidification

Renal acidification mechanism are usually examined in


children with suspected renal tubular acidosis.
Urine pH : The pH of a fresh specimen of urine is tested with
pH meter. A concentrated, fasting, morning sample of urine is
acidic.A pH of <5.5 virtually excludes distal renal tubular
acidosis.
Urine Anion Gap : Urine anion gap is the difference between
concentration of principal urinary cations(Na + k) &
anion(cl)This difference is expected to estimate the
unmeasured anions & cation,which normally include
ammonium & bicarbonate.Since the latter is mostly
reabsorbed ,urine anion gap is chiefly measure of ammonium
excretion.
39
Cont
In presence of systemic metabolic acidosis,ammonium
excretion is expected to be stimulated while the bicarbonate
excretion is minimal,hence,the urine anion gap should be ve
due to obligatory chloride excretion with ammonium.
In patients with renal tubular acidosis the gap remains +ve
due to impaired ammonium production.
Sodium Bicarbonate Loading Test : The Bicarbonate threshold
is the plasma bicarbonate level at which bicarbonate appears
in urine.
-The bicarbonate threshold is determined by infusion of
bicarbonate & increasing the plasma bicarbonate in a
stepwise manner to elevate he serum bicarbonate level to 23-
26mEq/l.
40
Cont
-3-5ml/kg sodium bicarbonate is administered orally or
Intravenously,which increase the urine pH to more than 7.4.
-Levels of bicarbonate & creatinine are measured in blood &
random urine specimens.
-Normally there is no bicaorbonaturia unless the plasma
bicarbonate level exceeds 23-24mEq/l.
-the urinary bicarbonate threshold is reduced is proximal renal
tubular acidosis.The Fractional Excretion of bicarbonate
(FEHCO3) is calculated by the formula :
FEHCO3 = urine HCO3 X plasma creatinine X 100
plasma HCO3 X urine creatinine
-The normal level of FEHCO3 are <5%.In proximal RTA,the
FEHCO3 usually exceed 15%.
41
Cont

Other tests for urine acidification are


-Urine PCO2
-Ammonium Chloride Loading test

42
Cont
OTHER INVESTIGATIONS
S.proteins : S.albumin level
S.cholesterol: in Nephrotic Sohypercholesterolemia.
Anti Streptococcal Antibody Titer : antibody titer against
hemolytic streptococcs is important for the diagnosis of
Poststreptococcal GN(PSGN).A titer of >200 IU/ml is +ve.
S.complement : measurement of C3 & C4 levels in bld. is
important for diagnosis of Postinfectious GN,
Membranoproliferative GN & Lupus Nephritis, where
decrease in C3 levels are +nt. The levels of C3 are increased in
active Rheumatoid arthritis. The normal range of S.C3 is 70 to
120 mg/dl & C4 20-50 mg/dl.
S.immunoglobulins : S.IgA levels are increased in abt 30-
40%patients with IgA nephropathy & HSP.
43
Cont
Antineutrophil cystoplasmic antibodies : are typically
detected in Wegners granulomatosis & In Pauci-Immune
Cresentric GN.

44
RENAL BIOPSY
Expert evaluation of renal histology is important in the
diagnosis of various renal parenchymal disease involving
glomeruli, tubulo-interstitium & small blood vessels.
The procedure has become has become
much simpler with the use of automatic
(biopsy gun,tru cut) devices & ultrasono
-graphic visualization of kidney.
INDICATIONS : Renal biopsy has a limited role in children.
Significant Value
-Streoid resistant nephrotic So
-Acute Renal Failure of Unknow Cause
-Rapidly Progressive Renal Failure
45
Cont
-Systemic disease(Henoch-schonlein Purpura,Lupus Hemolytic
Uremic So ,IgA nephropathy)
-Inherited Nephropathies e.g Alport So
-Renal allograft dysfunction
-Detection Of Calcineurin toxicity
Less Value
-Chronic renal Failure to ascertain etiology
-Non Nephrotic Range Proteinuria
-Microscopic Hematuria
-Steroid Sensitive Nephrotic So
A Renal Biopsy Is not required in uncomplicated cases of
Postinfectious GN & corticosteroid responsive nephrotic So

46
Cont
BIOPSY PROCEDURE
-A renal biopsy is usually made percutaneously
-A history of bleeding & clotting disorders should be obtained.
-PT, BT, Coagulation time & Platelet count is measured.
-BP should be in normal range
-In Patients with acute renal failure,dialysis should be done to
reduce azotemia & correct biochemical abnormalities before
the biopsy.
-Renal size & location are confirmed with an US before biopsy.
-The Patient should be kept fasting for abt 3-4 hrs.
-Local anaesthesia can be used

47
Cont
-The child lies in prone position with a
folded towel or bed sheet placed
under his lower ribs & epigastrium to
push the kidneys posteriorly &
stabilize their position.
-The entry of biopsy needle into the kidney,when it pierces the
renal capsule,is indicated by slight resistancce & once in kidney
it moves wit respiratory excrusions
-2 core of tissue(abt. 8-10 mm long)
are needed for adequate histological
examination.

48
Cont
-One core is fixed in buffered formaline & other in saline(for
immunofluorescencs study)
Interpretation of Renal Biopsy
The histology should be examined by light microscopy using
Hematoxylin & eosin(H & E),Periodic Schiff (PAS) & Silver
Methanamine staining In all cases, & special stains as
necessary.
Electron microscopy is very useful in several disorders e.g
Alport So, Membranoproliferative GN & thin Basement
Membrane Disease.

49
IMAGING
DIAGNOSTIC PROCEDURES
RADIONUCLIDE STUDIES

50
DIAGNOSTIC PROCEDURES
Plain X-Ray Film Of The Abdomen : The utility of a plain X-ray
film of abdomen has decreased with the introduction of US &
later CT scanning.Most UT disorders can be imaged using
these methods,which gives more information
than the Plain X-ray.The later still has a role in
detecting small renal calculi,ureteric calculi
with minimal or no proximal dilatation,
spinal evaluation in neurogenic states,
evaluation of metastatic bone disease from
a neuroblastoma & screneing for renal
osteodystrophy.

51
Cont
Excretory Urography : Newer techniques especially US in
combination with radionuclide studies have largely replaced
excretory urography & IVP(Intravenous Pyelography).
-After careful preparatn
on the previous evening
(a liquid diet,laxative)
2.5 -3 ml/kg of a
nonionic contrast agent
is administered intravenously.
-Intial film is taken at 5 mins. After contrast agent followed by
another at 10-15 mins. & a late pelvic film to visualize the UB.
-Excretory urography should be avoided in neonates bcoz of
their poor ability to concneterate contrast medium. 52
Cont
Ultrasonography : it provides
an excellent information
about the anatomy of the
urinary tract.
-High resolution images in
multiple planes may be
obtained.
-The procedure is ideally suited
for children since,it is painless & requires no sedation or
administration of any contrast reagent,& be carried out even
bedside.
-US guidance can be used in invasive procedures e.g. fine
needle aspiration & biopsy.
- 53
Cont
Quantitative measurements of renal growth is possible on 2D
US Doppler technique when used in conjunction with 2D
imaging is particularly informative.

The major drawback of US is that it is operator dependent.

54
Cont
Antenatal Ultrasonography : US during pregnancy can detect
fetal anomalies.Presence of dilation of urinary
system,echotexture of renal parenchyma,appearance of
urinary bladder & the amniotic fluid are carefully examined.
Vesicoureteric reflux is the commonest cause of dilated
urinary tract & pelviureteric junction obstruction that is
isolated hydronephrosis.
Oligohydramnios on US
indicates poor renal
function.

55
Cont
Computed Tomography (CT SCAN) : CT,besides providing
anatomical information,also gives functional status of the
kidneys if an IV contrast agent is used.
The main role of CT urinary tract imaging is for examining
mass lesions of the kidney,bladder or retroperitoneum that
secondarily affect the urinary
system.
These masses may be congenital
(teratoma), inflammatory(abscess),
traumatic(hematoma) or
neoplastic(wilms tumor).

WILMS TUMOR 56
Cont
CT scan can detect a non functioning or a
poorly functioning kidney.
With the advent of Multidetector Row CT
(MDCT),it is possible to acquire high
resolution images with faster speed &
hence,less motion blur in small children.
With MDCT it has become possible
to get high resolution reformatted
images in coronal & sagittal planes;
which is crucial for extent
assessment of renal or
retroperitoneal masses (e.g. extent
of IVC thrombus in wilms tumor)
57
Cont
Magnetic Resonance Imaging(MRI) :Though there are several
advantages of this imaging modality like nonionizing
nature,multiplaner
imaging capability &
superior soft tissue
contrast resolution,
its use is limited in
pediatric practice bcoz
of motion related
problem & requirement
of sedation & general
anaesthesia.
58
Cont
Important uses of MRI in pediatric
renal pathologies include MR
Urography in cases of hydronephrosis,
duplex moeity, ectopic ureter : MR
angiography in cases of suspected renal
artery stenosis.

The added advantage of MRI in


evaluation of renal masses is that IVC
thrombus can be detected without any
contrast.

59
Cont
Micturating Cystourethrogram : MCU is an important
procedure necessary for the diagnosis & evaluation of severity
of Vesicoureteric reflux, & detection of the abnormalities of
bladder & urethra.
The contrast agent
is introduced into
the bladder through
a catheter.
Films are taken while
child is voiding.
The catheter should be introduced with strict aseptic
precautions.

60
Cont
Patients at high-risk of systemic sepsis(infants,children with
dilated urinary tract,congenital heart disease0 should receive
prophylactic treatment with oral amoxicillin or parentral
gentamycin 30-60 mins. prior to procedure.

61
Cont
Special Imaging Procedures :
-Several other imaging procedures are employed to visualize
the urinary system.
-these include nephrostogram, ureterostogram, retrograde
pyelogram & angiography.
CHOICE OF IMAGING PROCEDURES
US evaluation is usually the 1st procedure in patient with
suspected urinary tract disease.
It is often diagnostic ( e.g. hydronephrosis,cystic disease of
kidney ) or provides enough information to suggest the next
appropriate investigation.

62
RADIONUCLIDE STUDIES

Radionuclide studies are complementary to structural imaging


methods of the pediatric urinary tract.
Nuclear medicine procedures are relatively noninvasive,
requring only an i.v injection.
They require neither fasting nor bowel preparation.
They can be performed on an outpatient basis without the
need for anaesthesia.
They have neither systemic toxic effects(e.g. osmotic
effect,hemodynamic overload) nor allergic reactions,with
minimal absorbed radiation dose.
Radionuclide studies & US evaluation of genitourinary
morphology have significantly reduced the need for i.v
urography. 63
Cont
Radiopharmaceuticals : radiopharmaceuticals used for
evaluation of the kidneys may be classified into three
principle groups.

A) Radiopharmaceuticals that are rapidly eliminated by the


kidneys & thus enable evaluation of filteration & drainage
function(Renal Dynamic Scintigraphy) namely 99mTc-
DTPA,99mTc-MAG & 99mTc-LL-EC.

B) Radiopharmaceuticals that concentrate in the renal


parenchyma for a sufficiently long time to enable detailed
scintigraphic mapping of regional functioning renal
parenchyma(Renal Cortical scintigraphy) namely 99mTc-
DMSA.
64
Cont

C) Radiopharmaceuticals are either used exclusively for


non-imaging clearance studies namely GFR (51Cr-
EDTA) or ERPF(131I-OIH) measurements or used for
both (99mTc-DTPA, 99mTc-MAG3 & 99mTc-LL-EC)

65
Cont

Static Renal Scan


The Radiopharmaceutical is 99mTc- DMSA.
It is given intravenously. Image is obtained in 2 hours.
It binds sufficiently to the renal tubules and lasts for several
hours. This will permit good renal cortical imaging.
The main clinical application
of DMSA scan is in acute
pyelonephritis in children.

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Acute Pyelonephritis in Children
-The diagnosis of AP in children is difficult based on clinical
and laboratory findings.
-Intravenous urography and renal sonography have a low
sensitivity and underestimate the degree of parenchymal
involvement.
-DMSA scan is highly sensitive for the diagnosis of acute
pyelonephritis in children.
-In acute stage of AP, segmental renal infection causes
inflammatory process which results in edema. Edema causes
focal vasculature pressure. This will result in ischemia.
-This stage manifests on the scan as focal reduced uptake.
-Later on, ischemia resolves completely in most cases or may
progress and scar develops in few cases
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Cont
On DMSA scan, the scar manifests as focal cortical defect.
The presence of renal scarring usually mandates prolonged
prophylactic antibiotics to prevent further attacks of AP and
further scarring.

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Cont

Renal Dynamic Imaging


Renogram is graphical representation of the arrival, uptake
& elimination of radiopharmaceutical by the kidneys.
Usually a tracer is injected as a bolus & data collection
starts immediately.
The flow of activity through kidneys is recorded for 35-45
mins. & computer reconstructs the renogram when user
marks the region of interest over the kidneys.
Renogram has a characteristic shape,& may be considered
as having three distinct phases.
Radiopharmaceuticals :Filtered agents (DTPA)
Tubular agents (MAG3) 69
Cont

70
Cont
Vascular Phase : The 1st phase consist of a rapid rise & sharp
fall in count rates during the 1st passage of the bolus after i.v
injection of 99mTc-DTPA.This is bcoz of low 1st pass extraction
of tracer by the kidney.This phase normally lasts for 30 secs in
99mTc-DTPA renogram.

But this phase merges


with subsequent phase
in 99mTc-MAG3
renogram bcoz of
high extraction
fraction.

71
Perfusion/Vascular phase : 30-60 images are taken over 1
minute immediately post injection.This phase givens an idea
about renal vasculature

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Cont
Cortical Transit Phase : This phase corresponds to the renal
handling of the radionuclide as it is taken up by the kidneys &
passes through the nephrons.In a well hydrated subject,the
second phase,the time to reach the peak lasts approximately
180-300 secs after the injection.The time to reach the peak
may be delayed by a variety of conditions,such as :
a) An obstructive process preventing or delaying excretion of
the tracer.
b) Renal artery stenosis causing a decrease in supply of tracer to
the kidney,
c) Dehydrated states producing low urine flow rate, or
d) Renal parenchymal disease.

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Uptake Phase : Image is taken every 15 seconds.
This phase represents radiopharmaceutical extraction from
blood stream.
Peak uptake is expected in 4-6 minutes post injection

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Excretory Phase : The period of declining amplitude after the
peak is the 3rd phase of renogram.The beginning of this phase
of the renogram corresponds to the time at which activity
starts moving away from the region-of-interest & appears in
the bladder.The 3rd phase of the renogram curve reflects
predominantly the excretory function function of the kidney
& measured in terms of its half time(t1/2), i.e the time taken
for the counts to decline to one half of the maximum count
rate.The excretory phase normally begins 5 mins after
injection & usually approaches the baseline about 20 mins
after the injection

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Renal perfusion phase

76
Renal uptake phase

77
Excretory Phase

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Intraventions During Renogram
-Diuretic Renogram :Frusemide is used to produce a rapid
diuresis & helps to differentiate obstructive dilatation from
nonobstructive dilatation of upper urinary tract. In the, latter
there is prompt clearing of the radionuclide.
-Captopril Renogram : ACE I temporarily dilates the efferent
arteries, which are normally vasoconstricted,& thus reduces
net filtration pressure & GFR, which is reflected in the
renogram.This is the basis of its use in patients with suspected
renal artery stenosis.

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Clinical Applications of Dynamic Imaging Studies
-Dilated collecting system (hydronephrosis)
-Residual function in atrophic kidney

-Dynamic renal scan is recommended as the initial screening


study in patients found on IVU or US to have hydronephrosis
without obvious cause ..
-It is used to follow patients
with managed (treated)
obstructive hydronephrosis

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GLOMERULAR FILTERATION RATE
The most useful measure of kidney function is the glomerular
filtration rate(GFR).
The total kidney GFR is equal to the sum of the filtration rates
in each of the functioning nephrons
GFR is measured indirectly through the concept of clearance.
Clearance = Ux X V
Px
Where Ux & Px are urine & plasma concenteration of the
substance X & V is urine flow rate(ml/min).
When a substance is freely filtered & not protein bound,& is
not reabsorbed,secreated or metabolised by the kidney,then
its clearance is similar to GFR.
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Renal Clearance of INULIN is the Gold Standard for
determination of GFR.
51Cr-EDTA clearance closely resembles Inulin clearance & it is
the radionuclide of choice for GFR estimation in Europe.
However, 99m Tc-DPTA is often the preferred agent, because
99m Tc-DPTA is inexpensive,easily available & renal imaging can

be simultaneously performed.
GFR can be estimated based upon either plasma clearance or
upon the tracer uptake by the kidneys.
The kidney of the newborn & young infant has several
functional limitations including a relatively low GFR
The increases from13-15ml/min/1.73m2 in the premature
infant to 15-60ml/min/1.73m2 in the full term infant,to 63-
80ml/min/1.73m2 at 8 wks of life. 82
Cont
Along with increase in GFR, tubular function of the kidney
gradually mature & reach adult level by 1-2 yrs of life.
Renal uptake of dynamic tracers may be lower in newborns
than older children & adults.
A normal dynamic radionuclide study in newborns during the
1st or 2nd week of life may demonstrate faint,delayed renal
uptake of the tracer with or without appearance in the
bladder at the expected time.

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Cont

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