OS 214

Renal Function Tests: Renal Imaging EXCRETORY

BLOCK B
Dr. Lynn Gomez Trans 2B | Exam
1

OUTLINE  so check first for kidney function before

I. Types of Renal Imaging doing IVP (<1.4)
A. Plain KUB  fairly accurate procedure when properly
B. Intravenous Pyelogram
done
C. Retrograde Pyelography
D. Ultrasound  at 30 minutes maximum visualization of
E. Radionucleide Studies Kidney parenchyma
F. Other Tests
II. Additional Notes
Paul and Jung:
quotable quote:
also known as do
“if you excretory
not know, do urography
not touch.” or intravenous urography
*** classmates. sorry but we were not able to obtain a copy of dr. gomez’s -- the modern interpretation of primum non nocere
powerpoint. So, ayun, tagpi-tagpi nalang itong aming additional trans requires intravenous injection of radiopaque contrast mat
(lecnotes, booknotes, and internet). hope this would suffice.***
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 patient preparation before an elective examination often i

such as castor oil, senna preparations (X-Prep), or bisacodyl (D
A. Plain KUB The contrast media are organic iodides that depend on the
are two types of contrast material in use: ionic and nonionic. T
 Has little specific information
iothalamate-based media, has been standard for more than 4
 from Paul and Jung  Contraindications to injection of intravenous contrast ma
patient in a supine position (1) hypersensitivity to the contrast agent
Includes the kidneys and the ureteral and (2) presence of combined renal and hepatic disease
bladder areas. (3) oliguria
Must be obtained before contrast medium is (4) a serum creatinine level higher than 2.5 to 3.0 mg/100 m
given for EXU (5) Insulin-Dependent Diabetes Mellitus (IDDM) in combinat
Renal shadow and Psoas muscle shadow are greater than 1.5 mg/dL)
seen along with radiopaque calculi, ureters (6) multiple myeloma (unless the patient can be kept well h
are not (7) history of severe allergy
Shadow of bladder, vesical calculi, (8) use of the oral hypoglycemic agent metformin (Glucoph
phleboliths, arterial plaques can be seen  Patients who are using metformin are at risk for severe lact
INFO: size, shape, and position of the high mortality - approximately 50%
kidneys, presence of calcium in cysts, tumors, it is recommended to stop metformin for 48 hours before
or stones can be detected along with vascular emergency studies should be weighed on a case-by-case
or lymph node calcifications in the area hours before the patient is restarted on the drug.
 Contraindications are relative: value of potential informatio
B. IntraVenous Pyelogram (IVP) risk in each patient

 More information with Intravenous pyelogram (a

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 non-
visualizable
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, FIGURE 1: The KIDS. A. Two kids blowing through a straw
in a balloon is analogous to the urinary system.B. Pebble
extrinsic mass obstructing a straw is analogous to a stone obstructing a
Adequacy of parenchymal thickness, ureter. C. One kid not blowing into a straw is analogous to
abnormality of cortical contour or papillary a non-functioning kidney. D. An absent kid is analogous to
an absent kidney.
appendage
Dilation or blinding of calyces, abnormal
position of kidney, reflex course of ureters,
variations

Clinical Radiology MRS: Analogy for IVP

 caution however in using IVP when GFR is
already low since the kidney is already
nonvisualizing

Monday, November 27, The End Page 1 of 4

2006
 OS 214
Renal Function Tests: Renal Imaging EXCRETORY
BLOCK B
Dr. Lynn Gomez Trans 2B | Exam
1

University Of Minessota Website: pyelolymphatic backflow (upper arrow).

Pyelotubular
 uses multiple radiographs at a particular sequence -showing backflow
contrast is outlined
enhancement (lower
of the arrow).
renal
There is also some extravasation in
vasculature (vascular phase), renal parenchyma (nephrogram phase), renal collecting system, the vicinity of
and ureters (pyelogram phase) the ureteropelvic junction, representing interstitial
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
indicative the structure,
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
Severe dehydration which the
Severe uremia – expectant poor contrast opacification of the urinary tract as a echogenicresult of
decreased glomerular filtration. central renal
Prior contrast reaction. sinus is visible.
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
pelves, calyces,  Simple Cysts - no internal echoes with sharply
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
Paul And Jung of the radiolucent cyst adjacent to the density of
the opacified parenchyma.
 generally used when the EXU has been unsatisfactory or inconclusive for visualization of the renal
collecting system and ureters
 Hydronephrosis—multilobulated
 cystoscopy and catheterization of the ureters are necessary for this examination fluid collection
 roentgenograms are obtained after direct instillation of contrast material (3 to 5 ml, intravenouswithin
contrast
agent diluted to 20%-30%) into the pelves through the catheters renal
 catheters are withdrawn, and another roentgenogram is obtained system
 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
medium no higher than 45 cm above renal level. bilateral

 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
 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
Backflow. This there is a little blunting of the calyces. Note the
retrograde minimal pyelolymphatic backflow on the right
pyelogram (arrow).
shows a marked
amount of

Monday, November 27, The End Page 2 of 4

2006
 OS 214
Renal Function Tests: Renal Imaging EXCRETORY
BLOCK B
Dr. Lynn Gomez Trans 2B | Exam
1
Bilateral hydronephrosis showing the value of Multiplanar capability allows wide range of imaging
delayed films. A: Intravenous urogram, obtained 15 planes
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 stricture-  Computerized Tomography (CT) - preenhanced
like narrowing, which is a little higher on the right  LT Renal angiography
than on the left.  Screening aortography
E. Radionucleide Studies  MRA and Contrast Angiography - parang
 very informative but expensive pinipicturan ang loob ng pasyente
1) 99mTc  Arteriography or Venography
2) DTPA—Diethylenetriaminepentaacetic acid
3) DMSA—2,3Dimercaptosialic acid
4) 131 I
5) OIH
 Indication for Nuclear Perfusion II Additional Notes
1) Quantify total renal function (overall GFR Cystatin C
and RPF)
2) Quantify the percentage contribution of
each overall renal function  a nonglycosylated protein that belongs to the
3) Detect obstruction cysteine protease inhibitors, cystatin
4) Detect (+) / (-) of normal renal superfamily - play an important role in the
parenchyma in suspecting mass lesion regulation of proteolytic damage to the
5) Evaluate renovascular disease cysteine proteases
 produced at a constant rate by nucleated
Normal renal cells
anatomy.  found in relatively high concentrations in
Coronal T1- many body fluids, especially in the seminal
weighted fluid, cerebrospinal fluid and synovial fluid
magnetic  low molecular weight (13.3 kDa) and positive
resonance charge at physiological pH levels facilitate its
image. glomerular filtration
Multiplanar
capability  reabsorbed and almost completely
allows wide catabolized in the proximal renal tubule
range of  because of its constant rate of production, its
imaging planes serum concentration is determined by
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  use of serum cystatin C as a marker of GFR is
well documented, and some authors have
 Magnetic Resonance Imaging (MRI) suggested that it may be more accurate than
serum creatinine for this purpose.
superior to CT Scan in ability to detect tumor
thrombus (in major vessels in distinguishing  blood level of cystatin C predicts survival after
renal hilar collecting vessels), adrenal mass one type of heart attack - a high level of
cystatin C level in the blood after a heart
lesions, pheochromocytoma
attack is an ominous sign because it reflects
the failure of the kidney to clear cystatin C
from the blood into the urine
Normal renal
anatomy.  mutation of the cystatin C gene is responsible
Coronal T1- for a type of amyloidosis in which deposits in
weighted the brain result in premature strokes,
magnetic intracranial hemorrhage, and dementia. This
resonance disease is called amyloidosis VI or
image. cerebroarterial amyloidosis. It is inherited
in an autosomal dominant manner.

Monday, November 27, The End Page 3 of 4

2006
 OS 214
Renal Function Tests: Renal Imaging EXCRETORY
BLOCK B
Dr. Lynn Gomez 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.

GFR (ml/min/1.73m2)
Age Mean Range (2SD)
Premature 47 29-65
2-8 days 38 26-60
4-28 days 48 28-68
35-95 days 58 30-86
1-5.0 months 77 41-103
6-11.9 months 103 49-157
12-19 months 127 63-191
2-12 years 127 89-165
Adult Male 131 88-174
Adult Female 117 87-147
TABLE 1: Normal Glomerular Filtration Rates (GFR)
at Different Ages

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.

Monday, November 27, The End Page 4 of 4

2006