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RESOLUTION NO. 29
BE IT RESOLVED,
that the American College of Radiology adopt the ACR–SPR Practice Parameter for the
Performance of Renal Scintigraphy
Sponsored By:
ACR Council Steering Committee
The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists, and clinical
medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology,
improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for
radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields.
The American College of Radiology will periodically define new practice parameters and technical standards for radiologic practice to help advance the
science of radiology and to improve the quality of service to patients throughout the United States. Existing practice parameters and technical standards
will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.
Each practice parameter and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has
been subjected to extensive review and approval. The practice parameters and technical standards recognize that the safe and effective use of diagnostic
and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published
practice parameter and technical standard by those entities not providing these services is not authorized.
Revised 2013 (Resolution 51)*
ACR–SPR PRACTICE PARAMETER FOR THE PERFORMANCE OF RENAL
SCINTIGRAPHY
PREAMBLE
This document is an educational tool designed to assist practitioners in providing appropriate radiologic care for
patients. Practice Parameters and Technical Standards are not inflexible rules or requirements of practice and are
not intended, nor should they be used, to establish a legal standard of care1. For these reasons and those set forth
below, the American College of Radiology and our collaborating medical specialty societies caution against the
use of these documents in litigation in which the clinical decisions of a practitioner are called into question.
The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the
physician or medical physicist in light of all the circumstances presented. Thus, an approach that differs from the
practice parameters, standing alone, does not necessarily imply that the approach was below the standard of care.
To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth
in the practice parameters when, in the reasonable judgment of the practitioner, such course of action is indicated
by the condition of the patient, limitations of available resources, or advances in knowledge or technology
subsequent to publication of the practice parameters. However, a practitioner who employs an approach
substantially different from these practice parameters is advised to document in the patient record information
sufficient to explain the approach taken.
1 Iowa Medical Society and Iowa Society of Anesthesiologists v. Iowa Board of Nursing, ___ N.W.2d ___ (Iowa 2013) Iowa Supreme Court refuses to find
that the ACR Technical Standard for Management of the Use of Radiation in Fluoroscopic Procedures (Revised 2008) sets a national standard for who may
perform fluoroscopic procedures in light of the standard’s stated purpose that ACR standards are educational tools and not intended to establish a legal
standard of care. See also, Stanley v. McCarver, 63 P.3d 1076 (Ariz. App. 2003) where in a concurring opinion the Court stated that “published standards or
guidelines of specialty medical organizations are useful in determining the duty owed or the standard of care applicable in a given situation” even though
ACR standards themselves do not establish the standard of care.
PRACTICE PARAMETER
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The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis,
alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to
always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment.
Therefore, it should be recognized that adherence to these practice parameters will not assure an accurate
diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable
course of action based on current knowledge, available resources, and the needs of the patient to deliver effective
and safe medical care. The sole purpose of these practice parameters is to assist practitioners in achieving this
objective.
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I.
INTRODUCTION
This practice parameter was revised collaboratively by the American College of Radiology (ACR) and the Society
for Pediatric Radiology (SPR) to guide physicians performing renal scintigraphy in adult and pediatric patients.
Renal scintigraphy involves the intravenous injection of a radiopharmaceutical, which is extracted from the blood
by the kidneys and imaged using a gamma camera. Estimation of renal function using a well counter may be
performed in conjunction with, or in lieu of, renal scintigraphy.
Properly performed, renal scintigraphy is a sensitive means method for detecting, evaluating, and quantifying a
variety of anatomic and physiologic abnormalities of the kidneys and urinary system. renal disorders
Pharmacologic manipulation may enhance the sensitivity and specificity in certain renal diseases. It also is
possible to accurately quantify some guidelines parameters of renal function. Although certain patterns are
suggestive of individual disease entities, correlation of abnormal findings with clinical information,
radiographs, computed tomography, magnetic resonance imaging, and other radiopharmaceutical imaging
and non-imaging examinations is frequently helpful for optimal diagnosis. As with all scintigraphic
examinations, correlation of findings with the results of other imaging and nonimaging procedures, as well as
with clinical information, is imperative for maximum diagnostic yield
The goal of renal scintigraphy is to enable the interpreting physician to detect anatomic and/or functional
abnormalities of the kidneys and/or urinary tract by interpreting producing images of diagnostic quality and/or
using reliable quantitative data.
Application of this parameter should be in accordance with the ACR–SPR Technical Standard for Diagnostic
Procedures Using Radiopharmaceuticals [1].
II.
INDICATIONS
Clinical indications for renal scintigraphy include, but are not limited to detection, evaluation, and/or
quantification of:
General indications for renal scintigraphy include, but are not limited to, evaluation and/or quantification of:
1. Renal perfusion and function, including differential (also known as split or relative) renal function
2. Glomerular filtration rate (GFR)
3. Effective renal plasma flow (ERPF)
Specific indications for renal scintigraphy include, but are not limited to, detection, evaluation, and/or
quantification of:
1. Urinary tract obstruction
2. Renovascular hypertension
3. Renal allograft perfusion and function and complications
4. Pyelonephritis and renal cortical scarring
5. Congenital and acquired renal abnormalities, including mass lesions
1. Renal function
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2.
3.
4.
5.
6.
7.
Congenital and acquired renal abnormalities, including mass lesions.
Urinary tract obstruction
Renovascular hypertension
Pyelonephritis and parenchymal scarring.
Renal allografts
Guidelines of renal function, including effective renal plasma flow (ERPF), glomerular filtration rate
(GFR), and differential (also known as split or relative) renal function.
For information on radiation risks to the fetus, see The ACR–SPR Practice Parameter for Imaging Pregnant or
Potentially Pregnant Adolescents and Women with Ionizing Radiation provides useful information on radiation
risks to the fetus regardless of source. Information on managing pregnant or potentially pregnant patients
undergoing nuclear medicine procedures is available from the International Commission on Radiological
Protection [2-4].
III.
QUALIFICATIONS AND RESPONSIBILITIES OF PERSONNEL
See the ACR–SPR Technical Standard for Diagnostic Procedures Using Radiopharmaceuticals [1].
IV.
SPECIFICATIONS OF THE EXAMINATION
The written or electronic request for renal scintigraphy should provide sufficient information to demonstrate the
medical necessity of the examination and allow for its proper performance and interpretation.
Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history
(including known diagnoses). Additional information regarding the specific reason for the examination or a
provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and
interpretation of the examination.
The request for the examination must be originated by a physician or other appropriately licensed health care
provider. The accompanying clinical information should be provided by a physician or other appropriately
licensed health care provider familiar with the patient’s clinical problem or question and consistent with the state
scope of practice requirements. (ACR Resolution 35, adopted in 2006)
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A. Radiopharmaceuticals
Radiopharmaceuticals for evaluation of the kidneys may be classified into 3 broad categories.
1. Tubular radiopharmaceuticals: mainly cleared by tubular secretion [5]
1. Technetium-99m mercaptoacetyl triglycine (MAG3) [5]
a. Kinetics:
Rapid extraction by tubular cells with secretion into the renal collecting system. Renal uptake is
reduced by poor renal perfusion and function but is not affected as severely as with technetium-99m
DTPA.
b. Indications:
i. Assess renal perfusion and differential function
ii. Assess urinary tract obstruction
iii. Assess renovascular hypertension
iv. Assess renal allograft assessment
v. Estimate effective renal plasma flow (ERPF)
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c. Administered Activity:
i. Adults: Up to 370 MBq (10 mCi)
ii. Children with angiographic phase: 5.55 MBq/kg (0.15 mCi/kg); Minimum 37 MBq (1 mCi) and
Maximum 148 MBq (4 mCi) [6]2
iii. Children without angiographic phase: 3.7 MBq/kg (0.10 mCi/kg); Minimum 37 MBq (1 mCi) and
Maximum 148 MBq (4 mCi) [6]2
a. Glomerular radiopharmaceuticals: mainly cleared by glomerular filtration
2. Technetium-99m diethylene triamine penta-acetic acid (DTPA)
a. Kinetics:
Excreted predominantly by glomerular filtration and can be used to measure GFR Predominant
excretion by glomerular filtration. It can be used to estimate GFR. Renal excretion of DTPA is
significantly affected by reduced renal perfusion and function.
b. Indications:
i. Assess renal blood flow and function
ii. Assess urinary tract obstruction
iii. Assess renovascular hypertension
iv. Assess renal allograft assessment
c. Administered Activity:
i. Adults: Up to 555 MBq (15 mCi)
ii. Children: 3.7 to 7.4 MBq/kg (0.1-0.2 mCi/kg). Minimum 37 MBq (1 mCi). Maximum 185 MBq
(5 mCi) [6]2
iii. GFR without imaging: 7.4 to 18.5 MBq (0.20 to 0.50 mCi)
3. Cortical radiopharmaceuticals: primarily incorporated by tubular cells
3. Technetium-99m dimercaptosuccinic acid (DMSA)
a. Kinetics:
This radiopharmaceutical is predominantly incorporated predominantly by Predominant
incorporation into renal tubular cells with a minor component of glomerular filtration. It is an
excellent renal parenchymal imaging radiopharmaceutical primarily that can be used for detecting and
defining characterizing pyelonephritis and renal cortical scars.
Indications:
i. Detect and define pyelonephritis or renal cortical scars
ii. Assess renal shape, size, and position
iii. Assess relative functional cortical mass (eg, differential/split/relative function)
Administered Activity:
i. Adults: Up to 185 MBq (5 mCi)
ii. Children: 1.85 MBq/kg (0.05 mCi/kg). Minimum 18.5 MBq (0.5 mCi). Maximum 100 MBq (2.7
mCi) [6]2
a. Technetium-99m mercaptoacetyl triglycine (MAG3)
This radiopharmaceutical is rapidly extracted and secreted by tubular cells in a manner that is
qualitatively similar to the action of orthoiodohippurate (OIH). Renal uptake of MAG3 is reduced by
poor function but is not as severely as with technetium-99m diethylene triamine penta-acetic acid
2 Alternative pediatric radiopharmaceutical dosing is proposed as the EANM Dosage Card [5], which may also be found at
http://www.eanm.org/publications/dosage_calculator.php?nav1d-285.
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(DTPA). MAG3 may be used quantitatively or qualitatively for evaluating obstructive uropathy,
renovascular hypertension, and renal allografts and has been used to estimate ERPF. Administered
activity of up to 10 millicuries (370 MBq) is used for adults. administered activity for children should
be determined based on body weight and should be as low as reasonably achievable for diagnostic
image quality.1 [7]. Pediatric administered activity ranges from 0.05 to 0.1 millicuries (1.85 to 3.7
MBq) per kilogram, with a minimum of 0.5 millicuries (18.5 MBq) and a maximum of 5.0 millicuries
(185 MBq)Error! Bookmark not defined..
2. Glomerular radiopharmaceuticals: mainly cleared by glomerular filtration
a.
Technetium-99m diethylene triamine penta-acetic acid (DTPA)
This radiopharmaceutical is excreted predominantly by glomerular filtration and can be used to
measure GFR. excretion by the kidneys is significantly affected by reduced renal function. The
radiopharmaceutical may be used to assess renal blood flow and function, renal allografts,
renovascular hypertension, and obstructive uropathy. For dynamic renal scintigraphy, administered
activity of up to 15 millicuries (555 MBq) may be given to adults. If the examination is performed for
calculation of GFR without imaging, the administered activity may be reduced to 0.20 to 0.50
millicurie (7.4 to 18.5 MBq). Administered activity for children should be determined based on body
weight and should be as low as reasonably achievable for diagnostic image quality. For children,
administered activities are typically in the range of 0.1 to 0.2 millicurie (3.7 to 7.4 MBq) per
kilogram, with a minimum of 1.0 millicurie (37 MBq) and a maximum of 5.0 millicuries [7] (185
MBq).
b. Iodine-125 iothalamate
This radiopharmaceutical is used in administered activities of 0.01 to 0.05 millicurie (0.37 to 1.85
MBq) for the nonimaging assessment of GFR.
3. Cortical radiopharmaceuticals: primarily incorporated by tubular cells
a. Technetium-99m dimercaptosuccinic acid (DMSA)
This radiopharmaceutical is predominantly incorporated by renal tubular cells with a minor
component of glomerular filtration. It is an excellent parenchymal imaging radiopharmaceutical,
primarily used for detecting and defining pyelonephritis and renal cortical scars. Technetium-99m
DMSA is also is used to assess the size, shape, position, and relative functional cortical mass of the
kidneys. Administered activity of up to 5.0 millicuries (185 MBq) may be given to adults.
Administered activity for children should be determined based on body weight and should be as low
as reasonably achievable for diagnostic image quality. For children, an administered activity of 0.05
to 0.1 millicurie (1.85 to 3.7 MBq) per kilogram is usually given, with a minimum of 0.3 millicurie
(11.1 MBq) and a maximum of 3.0 millicurie (111 MBq) [7].
B. Radionuclide Renography
Radionuclide renography refers to serial imaging after intravenous administration of technetrium-99m MAG3 or
technetium-99m DTPA. or technetium-99m MAG3. It is used for qualitative and quantitative evaluation of
differential renal function A commonly used technique involves dynamic acquisition of 1 to 2 second images for
1 minute (angiographic or vascular phase), followed by 15 to 60 second images for 20 to 30 minutes (functional
uptake, cortical transit, and excretion phases). If evaluation of renal perfusion is not needed, the examination is
performed without the first angiographic/vascular phase.
Qualitative evaluation of regional renal perfusion, differential function, and cortical transit of radiopharmaceutical
can be performed by visual analysis. Quantitative evaluation of cortical function and collecting system drainage is
made using regions-of-interest that typically are applied to each whole kidney. A background region-of-interest is
placed overlying soft tissue adjacent to each kidney. Differential renal function is calculated based on the relative
counts accumulated in each kidney during the second minute after injection of the radiopharmaceutical.
Occasionally, it may be helpful to approximate regions-of-interest to the renal cortex and the renal collecting
system, although absolute segmentation of cortex and renal collecting system is difficult. If there is suspected
ureteral obstruction or megaureter, regions-of-interest may be applied to the ureters. Depending on the regions-ofinterest drawn, the time-activity curves will reflect the functional uptake/accumulation and clearance of
radiopharmaceutical in the whole kidney, renal cortex, renal collecting system, or ureter. The regions of interest
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are typically drawn around the whole kidneys, but occasionally are limited to the renal cortex if a considerable
amount of collecting system activity is present. A background region of interest is placed adjacent to each kidney.
Depending on the regions of interest drawn, the time-activity curves will reflect the functional clearance of the
whole kidney, renal cortex, or collecting system. The differential renal function is calculated based on the relative
counts accumulated in each kidney during the second minute after injection of the radiopharmaceutical
C. Diuresis Renography
Diuresis renography is used to can evaluate the severity of urinary tract obstruction and can differentiate an
obstructed collecting system from a dilated but nonobstructed collecting system. from a dilated system with
urodynamically significant obstruction It is also is used for postoperative assessment of the useful for assessing
functional and urodynamic results of corrective surgery.
Diuresis renography is performed by intravenous administration of a loop diuretic (usually furosemide, although
other diuretics have been used) in conjunction with radionuclide renography. The usual dose of furosemide is 0.5
to 1.0 mg/kg (1 mg/kg in children), with a maximum dosage of 40 mg. Patients on chronic diuretic therapy likely
will be unresponsive to a small dose of furosemide and typically are administered their usual dose of furosemide
for diuretic renography. It can be helpful to coordinate timing of renography with the medication schedule to
avoid starting the renal scintigraphic examination during a pre-existing diuresis.
It is important to ensure that the patient is well hydrated prior to performing diuresis renography. Intravenous
fluid infusion is particularly useful in children and can be performed during the initial 20 minute renogram. A full
or distended bladder can prolong renal collecting system drainage, and depending on clinical circumstances, an
indwelling bladder catheter may be useful for adequate assessment of upper tract obstruction [8].
Different approaches to diuresis renography are characterized by the time of furosemide administration in relation
to the time of radiopharmaceutical administration. The most commonly used approach (referred to as F +20) is
intravenous administration of furosemide at or soon after the completion of 20minute (or 30 minute) radionuclide
renography; dynamic 15 second to 60 second renal images are obtained for another 20 to 30 minutes. Other
approaches include administering furosemide 15 minutes prior to radiopharmaceutical administration (F-15) or at
the time of radiopharmaceutical administration (F-0). Region-of-interest analysis of the images obtained during
the diuretic phase are used for quantitative analysis of collecting system drainage. A commonly used technique
includes intravenous administration of technetium-99m MAG3 or technetium-99m DTPA and acquisition of
dynamic 15-60 second posterior renal images for 20 to 30 minutes [8,9]. Furosemide, 0.5 mg/kg (1 mg/kg for
children) with a maximum dose of 40 mg, is then administered intravenously, and dynamic 15-60 second renal
images are obtained for another 20 to 30 minutes (F+20). Other techniques include administering furosemide 15
minutes prior to (F-15) or at the time of (F0) radiopharmaceutical administration. The initial set of images is used
for evaluating differential renal function. The images obtained after administration of furosemide are used for
quantitative analysis of postdiuresis clearance of the radiopharmaceutical from the dilated collecting system(s).
Regions of interest, including the entire dilated collecting system(s), are drawn and a background subtracted timeactivity curve is generated
Diuresis renography is usually is performed with the patient in the supine position. This may cause result in
delayed clearance of the tracer radiopharmaceutical from some a dilated but nonobstructed collecting systems.
Therefore, an additional posterior static image after the patient has been in an upright position for 10 to 15
minutes will may help to assess gravity-assisted clearance [8].
It is important to ensure that the patient is well-hydrated. Intravenous fluid infusion is particularly useful in
children. A distended bladder may prolong renal collecting system drainage depending on clinical circumstances,
an indwelling bladder catheter may be [8] necessary to assess adequately for obstruction of the upper tracts.
In children, particularly in neonates, the natural history of prenatal hydronephrosis and possible urinary tract
obstruction can be variable. Multiple diuretic renograms over time may be needed to detect gradual improvement
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or worsening of urinary tract drainage. In neonates, renal function continues to mature after birth, and renal
immaturity during the first few months after birth may delay uptake and clearance of tubular
radiopharmaceuticals. Ideally, renography will be delayed until at least 3 months of age to allow for renal
maturation. If this is not possible, then the diuretic renogram must be interpreted in the context of renal
immaturity.
The natural history of hydronephrosis in children, particularly in neonates, is variable, and definitive diagnosis of
obstructive uropathy on a single diuresis renogram is often difficult. Multiple examinations at appropriate
intervals may be needed to detect gradual improvement or worsening of the postdiuresis drainage. Therefore,
whatever technique is used, it should be standardized in order to allow meaningful comparison of the serial
examinations in each patient
D. Captopril (ACE Inhibitor) Renography
Renovascular hypertension is caused by hemodynamically significant stenosis of the main renal artery or one of
its branches. Most hypertension is essential (idiopathic), with less than 5% having a demonstrated renovascular
etiology. The prevalence of renovascular hypertension is somewhat higher in patients with risk factors that
include severe hypertension and end-stage renal disease [10]. However, renal artery stenosis may be present but
not be the etiology of the patient’s hypertension. Thus, the goal of ACE-1 renography is to identify the subgroup
of patients in whom hypertension is due to renal artery stenosis and who could potentially respond to an
intervention, such as revascularization [11]. However; renal artery stenosis may be present but not be the etiology
of the patient’s hypertension. Therefore, the goal of renal scintigraphy in the evaluation of hypertensive patients is
to identify those who have renal artery stenosis with associated renin-dependent hypertension and would benefit
from revascularization [11]
Imaging assessment for renovascular hypertension, including scintigraphy, is most appropriate in patients in
whom there is a high index of suspicion. Patients with a low index of suspicion usually have essential
hypertension that can be well controlled medically, and in these patients imaging is not generally indicated.
In the presence of hemodynamically significant renal artery stenosis, renal perfusion pressure is reduced, resulting
in activation of activating the renin-angiotensin system. Angiotensin II causes selective constriction of the
efferent arterioles and raises the pressure gradient across the glomerular capillary membrane. Because of this
autoregulatory mechanism, the GFR is maintained and conventional renal scintigraphy may be normal. In these
patients, blockade of the conversion of angiotensin I to angiotensin II by administering angiotensin converting
enzyme (ACE) inhibitors causes dilatation of the efferent arterioles. This leads to a significant but reversible
decrease in GFR that is detectable on renal scintigraphy.
The choice of radiopharmaceutical, ACE inhibitor, and technique of examination varies among institutions.
Technetium-99m MAG3 is preferred, but technetium-99m DTPA may be used. Renal scintigraphy is performed
approximately 1 hour after oral administration of 25 to 50 milligrams of captopril or 10 to 20 minutes after
intravenous injection of 40 micrograms/kg (maximum 2.5 mg) of Enalaprilat. The usual administered dose
dosage of captopril in children is 1 mg/kg, with a maximum of 50 mg.
Food ingestion within 4 hours prior to captopril administration may decrease absorption and test accuracy [12].
Blood pressure should be measured before administration of the ACE inhibitor and monitored every 10 to 15
minutes. An intravenous line should be kept in place to allow prompt fluid replacement if the patient becomes
hypotensive. Furosemide (0.25 mg/kg, maximum 20 mg) given intravenously at the time of radiopharmaceutical
administration decreases radiopharmaceutical retention in the collecting systems and may facilitate detection of
cortical retention of the radiopharmaceutical. The patient should be well hydrated, especially if furosemide is will
be used [12].
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Chronic use of ACE inhibitors may decrease the sensitivity of ACE inhibitor renography. the test Ideally, ACE
inhibitors should be are discontinued for 3 to 7 days before the test, depending on their the half-life of the
specific ACE inhibitor. If stopping the patient’s ACE inhibitor is not possible, the study may examination still
may be performed [11,12].
One protocol is to obtain perform a baseline scan without an prior ACE inhibitor administration, followed (on
the same or following day) by a repeat examination second scan performed after administration of an ACE
inhibitor [11]. on the same or following day The combined examinations help Comparison of the 2 scans helps
to detect subtle ACE inhibitor induced scintigraphic abnormalities produced by ACE inhibition.
An alternative protocol is to obtain perform the first scan after administration of examination with an an ACE
inhibitor first [12]. A normal examination indicates a low probability for renovascular hypertension and obviates
the need for a baseline examination without an ACE inhibitor. If the examination with an ACE inhibitor is
abnormal, a baseline examination is performed on a following day. obtained the next day or later
With the use of intravenous Enalaprilat and technetium-99m MAG3 (but not technetium-99m DTPA), both the
baseline and post-ACE inhibitor scans can be completed within 60 to 90 minutes. After administration of 1 to 3
mCi of technetium-99m MAG3, a baseline scan is performed for 20 to 30 minutes. Subsequently, 40 mg/kg
(maximum 2.5 mg) of Enalaprilat is administered intravenously. Ten to twenty minutes later, 8 to 10 mCi of
technetium-99m MAG3 is administered, and the second scan is performed for 20 to 30 minutes [13].
E. Evaluation of Renal Allografts
Renal scintigraphy has been deemed “usually appropriate” in the assessment of renal allograft dysfunction and as
a postoperative screening examination for surgical complications. Technetium-99m MAG3 or technetium-99m
DTPA may be used. for evaluating renal allografts Renal perfusion images are obtained using a technique similar
to that outlined in section IV.B, except that an anterior projection is used and is centered over the lower abdomen
and pelvis. It is possible to assess the presence or absence of renal perfusion, urine leaks, cortical infarcts,
lymphoceles, hematomas, acute tubular necrosis, collecting system obstruction, urine leaks, nephrotoxic effect of
medications (eg, cyclosporin A), and rejection. Comparison of serial examinations will enhance detection of
subtle physiological changes [14,15].
F. Renal Cortical Imaging
The radiopharmaceutical for renal cortical imaging is technetium-99m DMSA. In most cases, optimal
parenchymal imaging can be obtained 2 to 4 hours after radiopharmaceutical administration. injection If there
is significant hydronephrosis, delayed images imaging at 24 hours or administration of furosemide prior to
delayed imaging may be helpful. If there is no retention of tracer radiopharmaceutical in the collecting system,
relative renal function can be calculated. When assessing differential renal function in children with vesicoureteral
reflux, refluxed radiopharmaceutical may interfere with accurate quantification [16].
In adults, between 500,000 and 1,000,000 counts per image are desirable. At least 300,000 counts or 5 minutes
per image should be used when imaging children [17]. A 256 × 256 matrix is preferred. Pinhole (4 mm aperture)
images may be useful, especially in infants. Pinhole images should be acquired for a minimum of 100,000 to
150,000 counts or 10 minutes per image. At a minimum, posterior and both posterior oblique views should be
obtained. When imaging a “horseshoe” or pelvic kidney, anterior images should also be obtained. Single-photonemission computed tomography (SPECT) imaging may also be performed, although no definitive improvement in
sensitivity has been demonstrated, and false-positive SPECT defects may decrease specificity [18] Determination
of differential renal function should be performed on the posterior planar image using a parallel-hole collimator.
Background and depth corrections are optional. Depth correction, which can be accomplished by using the
geometric mean, should be considered when there is a major variation or abnormality in the shape or location of
the kidneys such as with a “horseshoe or pelvic kidney. Single photon emission computed tomography
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(SPECT) imaging also may be performed, although no definitive improvement in sensitivity has been
demonstrated, and false-positive SPECT defects may decrease specificity [18].
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Reporting should be in accordance with the ACR Practice Parameter for Communication of Diagnostic Imaging
Findings [23].
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G. Estimation of GFR
The radiopharmaceutical used for estimating GFR are is technetium-99m DTPA. and iodine-125 iothalamate
Numerous protocols are available, some of which involve imaging [5,17,19-21]. Whichever protocol is used, it is
imperative that the technique is meticulous and that the protocol is followed assiduously.
H. Estimation of ERPF
Technetium-99m MAG3 does not provide a true ERPF measurement, but it provides a value that can be
extrapolated to an ERPF equivalent measurement. Numerous protocols are available, some of which involve
imaging [5,19,22]. Whichever protocol is used, it is imperative that the technique is meticulous and that the
protocol is followed assiduously.
V.
EQUIPMENT
A gamma camera with a parallel-hole collimator is required. When magnification is desired, a pinhole collimator
may be used. For adults, a large-field-of-view gamma camera (400 mm) is desirable, but for children a smallfield-of-view camera (250 to 300 mm) is also acceptable. If a large-field-of-view camera is used in a pediatric
patient, “zoom” or pinhole collimation may be used. For most situations using technetium-99m-labeled tracers
radiopharmaceuticals, low-energy all-purpose/general all-purpose (LEAP/GAP) collimators are sufficient. If
renal cortical anatomic detail is desired, a high-resolution collimator will improve image quality, provided the
count density is adequate.
For digital acquisition, a 128 × 128 matrix is the minimum necessary, but a 256 × 256 matrix may be preferred.
SPECT (or SPECT/CT in adults) renal imaging using technetium-99m DMSA may be helpful in some
circumstances.
VI.
DOCUMENTATION
The report should include the radiopharmaceutical, used and the dose administered activity, and route of
administration, as well as any other pharmaceuticals administered, also with dose dosage and route of
administration.
VII.
RADIATION SAFETY
Radiologists, medical physicists, registered radiologist assistants, radiologic technologists, and all supervising
physicians have a responsibility for safety in the workplace by keeping radiation exposure to staff, and to society
as a whole, “as low as reasonably achievable” (ALARA) and to assure that radiation doses to individual patients
are appropriate, taking into account the possible risk from radiation exposure and the diagnostic image quality
necessary to achieve the clinical objective. All personnel that work with ionizing radiation must understand the
key principles of occupational and public radiation protection (justification, optimization of protection and
application of dose limits) and the principles of proper management of radiation dose to patients (justification,
optimization and the use of dose reference levels)
http://www-pub.iaea.org/MTCD/Publications/PDF/Pub1578_web-57265295.pdf
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Facilities and their responsible staff should consult with the radiation safety officer to ensure that there are
policies and procedures for the safe handling and administration of radiopharmaceuticals and that they are
adhered to in accordance with ALARA. These policies and procedures must comply with all applicable radiation
safety regulations and conditions of licensure imposed by the Nuclear Regulatory Commission (NRC) and by
state and/or other regulatory agencies. Quantities of radiopharmaceuticals should be tailored to the individual
patient by prescription or protocol
Nationally developed guidelines, such as the ACR’s Appropriateness Criteria®, should be used to help choose the
most appropriate imaging procedures to prevent unwarranted radiation exposure.
Additional information regarding patient radiation safety in imaging is available at the Image Gently® for
children (www.imagegently.org) and Image Wisely® for adults (www.imagewisely.org) websites. These
advocacy and awareness campaigns provide free educational materials for all stakeholders involved in imaging
(patients, technologists, referring providers, medical physicists, and radiologists).
Radiation exposures or other dose indices should be measured and patient radiation dose estimated for
representative examinations and types of patients by a Qualified Medical Physicist in accordance with the
applicable ACR technical standards. Regular auditing of patient dose indices should be performed by comparing
the facility’s dose information with national benchmarks, such as the ACR Dose Index Registry, the NCRP
Report No. 172, Reference Levels and Achievable Doses in Medical and Dental Imaging: Recommendations for
the United States or the Conference of Radiation Control Program Director’s National Evaluation of X-ray
Trends. (ACR Resolution 17 adopted in 2006 – revised in 2009, 2013, Resolution 52).
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Nuclear medicine and molecular imaging examinations should administer the lowest activity to obtain
images of diagnostic quality. National initiatives have partnered to provide such dosage optimization for
adults and dosage optimizing calculators for pediatric patients. The following is a web link for this
information and several references: www.imagegently.org. For further information, see the ACR–AAPM
Practice Parameter for Reference Levels and Achievable Administered Activity for Nuclear Medicine and
Molecular Imaging [6,24,25].
VIII.
QUALITY CONTROL AND IMPROVEMENT, SAFETY, INFECTION CONTROL, AND
PATIENT EDUCATION
Policies and procedures related to quality, patient education, infection control, and safety should be developed and
implemented in accordance with the ACR Policy on Quality Control and Improvement, Safety, Infection Control,
and Patient Education appearing under the heading Position Statement on QC & Improvement, Safety, Infection
Control, and Patient Education on the ACR website (http://www.acr.org/guidelines).
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Equipment performance monitoring should be in accordance with the ACR–AAPM Technical Standard for
Medical Nuclear Physics Performance Monitoring of Gamma Cameras [26].
ACKNOWLEDGEMENTS
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This practice parameter was revised according to the process described under the heading The Process for
Developing ACR Practice Parameters and Technical Standards on the ACR website
(http://www.acr.org/guidelines) by the Committee on Practice Parameters and Technical Standards – Nuclear
Medicine and Molecular Imaging of the ACR Commission on Nuclear Medicine and Molecular Imaging and the
Committee on Practice Parameters – Pediatric Radiology of the ACR Commission on Pediatric Radiology, in
collaboration with and the SPR.
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Collaborative Committee – members represent their societies in the initial and final revision of this practice
parameter
ACR
Chun K. Kim, MD, Chair
Murray D. Becker, MD, PhD, FACR
Frederick Grant, MD
Rathan M. Subramaniam, MD, PhD, MPH
SPR
Deepa R. Biyyam, MBBS
Neha Kwatra, MD
S. Ted Treves, MD
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Committee on Practice Parameters and Technical Standard – Nuclear Medicine and Molecular Imaging
(ACR Committee responsible for sponsoring the draft through the process)
Kevin P. Banks, MD, Co-Chair
Richard K.J. Brown, MD, FACR, Co-Chair
Twyla B. Bartel, DO
Murray D. Becker, MD, PhD, FACR
Erica J. Cohen, DO, MPH
Joanna R. Fair, MD
Perry S. Gerard, MD, FACR
Erin C. Grady, MD
Edward D. Green, MD
Jennifer J. Kwak, MD
Chun K. Kim, MD
Charito Love, MD
Joseph R. Osborne, MD, PhD
Rathan M. Subramaniam, MD, PhD, MPH
Stephanie P. Yen, MD
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Committee on Practice Parameters – Pediatric Radiology
(ACR Committee responsible for sponsoring the draft through the process)
Beverley Newman, MB, BCh, BSc, FACR, Chair
Lorna P. Browne, MB, BCh
Timothy J. Carmody, MD, FACR
Brian D. Coley, MD, FACR
Lee K. Collins, MD
Monica S. Epelman, MD
Lynn Ansley Fordham, MD, FACR
Kerri A. Highmore, MD
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Sue C. Kaste, DO
Tal Laor, MD
Terry L. Levin, MD
Marguerite T. Parisi, MD, MS
Sumit Pruthi, MBBS
Nancy K. Rollins, MD
Pallavi Sagar, MD
M. Elizabeth Oates, MD, Chair, Commission on Nuclear Medicine and Molecular Imaging
Rathan M. Subramaniam, MD, PhD, MPH, Vice Chair, Commission on Nuclear Medicine and Molecular
Imaging
Marta Hernanz-Schulman, MD, FACR, Chair, Commission on Pediatric Radiology
Jacqueline A. Bello, MD, FACR, Chair, Commission on Quality and Safety
Matthew S. Pollack, MD, FACR, Chair, Committee on Practice Parameters and Technical Standards
Comments Reconciliation Committee
Darlene F. Metter, MD, FACR, Chair
Richard Strax, MD, FACR, Co-Chair
Kimberly E. Applegate, MD, MS, FACR
Kevin P. Banks, MD
Murray D. Becker, MD, PhD, FACR
Jacqueline A. Bello, MD, FACR
Deepa R. Biyyam, MBBS
Richard K.J. Brown, MD, FACR
Kate A. Feinstein, MD, FACR
Frederick Grant, MD
Marta Hernanz-Schulman, MD, FACR
William T. Herrington, MD, FACR
Chun K. Kim, MD
Neha Kwatra, MD
Paul A. Larson, MD, FACR
Beverley Newman, MD, BCh, BSc, FACR
M. Elizabeth Oates, MD
Matthew S. Pollack, MD, FACR
Rathan M. Subramaniam, MD, PhD, MPH
Timothy L. Swan, MD, FACR, FSIR
S. Ted Treves, MD
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http://www.acr.org/~/media/5E5C2C7CFD7C45959FC2BDD6E10AC315.pdf. Accessed December 23,
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2. American College of Radiology. ACR-SPR practice parameter for imaging pregnant or potentially
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3. Demeter S, Applegate KE, Perez M. Internet-based ICRP resource for healthcare providers on the
risks and benefits of medical imaging that uses ionising radiation. Ann ICRP 2016; 45:148-155.
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5. Blaufox MD. Procedures of choice in renal nuclear medicine. J Nucl Med 1991; 32:1301-1309.
6. American College of Radiology. ACR-AAPM practice parameter for reference levels and achievable
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Available at:
http://www.acr.org/~/media/3B6B6F39D0214495BCA6D5D2E9900A56.pdf. Accessed April 20, 2016.
7. Lassmann M, Treves ST. Pediatric Radiopharmaceutical Administration: harmonization of the 2007
EANM Paediatric Dosage Card (Version 1.5.2008) and the 2010 North American Consensus guideline.
Eur J Nucl Med Mol Imaging 2014; 41:1636.
8. Conway JJ, Maizels M. The "well tempered" diuretic renogram: a standard method to examine the
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9. O'Reilly P, Aurell M, Britton K, Kletter K, Rosenthal L, Testa T. Consensus on diuresis renography for
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12. Taylor A, Nally J, Aurell M, et al. Consensus report on ACE inhibitor renography for detecting renovascular
hypertension. Radionuclides in Nephrourology Group. Consensus Group on ACEI Renography. J Nucl Med
1996; 37:1876-1882.
13. Sfakianakis GN, Georgiou M, Cavagnaro F, Strauss J, Bourgoignie J. Fast protocols for obstruction
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14. Boubaker A, Prior JO, Meuwly JY, Bischof-Delaloye A. Radionuclide investigations of the urinary tract in
the era of multimodality imaging. J Nucl Med 2006; 47:1819-1836.
15. Dubovsky EV, Russell CD, Bischof-Delaloye A, et al. Report of the Radionuclides in Nephrourology
Committee for evaluation of transplanted kidney (review of techniques). Semin Nucl Med 1999; 29:175-188.
16. Piepsz A, Blaufox MD, Gordon I, et al. Consensus on renal cortical scintigraphy in children with urinary tract
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17. Piepsz A, Ham HR. Pediatric applications of renal nuclear medicine. Semin Nucl Med 2006; 36:16-35.
18. Brenner M, Bonta D, Eslamy H, Ziessman HA. Comparison of 99mTc-DMSA dual-head SPECT versus highresolution parallel-hole planar imaging for the detection of renal cortical defects. AJR Am J Roentgenol 2009;
193:333-337.
19. Blaufox MD, Aurell M, Bubeck B, et al. Report of the Radionuclides in Nephrourology Committee on renal
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20. Gates GF. Glomerular filtration rate: estimation from fractional renal accumulation of 99mTc-DTPA
(stannous). AJR Am J Roentgenol 1982; 138:565-570.
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21. Gordon I, Anderson PJ, Orton M, Evans K. Estimation of technetium-99m-MAG3 renal clearance in children:
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22. Russell CD, Taylor A, Eshima D. Estimation of technetium-99m-MAG3 plasma clearance in adults from one
or two blood samples. J Nucl Med 1989; 30:1955-1959.
23. American College of Radiology. ACR practice parameter for communication of diagnostic imaging
findings. Available at: http://www.acr.org/~/media/C5D1443C9EA4424AA12477D1AD1D927D.pdf.
Accessed December 23, 2015.
24. Fahey FH, Bom HH, Chiti A, et al. Standardization of Administered Activities in Pediatric Nuclear
Medicine: A Report of the First Nuclear Medicine Global Initiative Project, Part 2-Current Standards
and the Path Toward Global Standardization. J Nucl Med 2016; 57:1148-1157.
25. Fahey FH, Ziniel SI, Manion D, Baker A, Treves ST. Administered Activities in Pediatric Nuclear
Medicine and the Impact of the 2010 North American Consensus Guidelines on General Hospitals in
the United States. J Nucl Med 2016; 57:1478-1485.
26. American College of Radiology. ACR-AAPM technical standard for medical nuclear physics
perfomance
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2015.
*Practice guidelines and technical standards are published annually with an effective date of October 1 in the year
in which amended, revised, or approved by the ACR Council. For practice guidelines and technical standards
published before 1999, the effective date was January 1 following the year in which the practice or technical
standard was amended, revised, or approved by the ACR Council.
Development Chronology for this Practice Parameter
1995 (Resolution 30)
Revised 1998 (Resolution 19)
Revised 2003 (Resolution 16)
Amended 2006 (Resolution 35)
Revised 2008 (Resolution 12)
Revised 2013 (Resolution 51)
Amended 2014 (Resolution 39)
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