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A 60 y/o WF with h/o end-stage renal disease status
post renal transplant in May 2007 due to focal segmental
glomerulosclerosis (FSGS). She presents with hematuria with
borderline acute rejection.
PMH: ESRD s/p renal transplant May 2007 PUD
recurrent UTIs trigeminal neuralgia
osteoporosis hyperparathyroidism
anemia of chronic disease
MPA: Prograf 2 mg BID since '99 Hydromorphone
Prednisone 40 mg Valcyte
Myfortic 360 mg BID Raloxifene
Metoprolol Tacrolimus
Protonix Fosamax
Aspirin Calcium carbonate
ALLERGIES: SULFA, CODEINE.
NUCLEAR MEDICINE: 9.9 mCi 99m-Technetium MAG3 was
given with 40 mg furosemide given 15 minutes following injection of
MAG3.
FINDINGS: There is delayed perfusion to the superior pole of the
transplant kidney.
On functional images, there is decreased parenchymal function in the
superior half of the transplant kidney, with an abrupt delineation
between upper and lower poles. Mild activity in the right upper
quadrant likely relates to physiologic hepatobiliary excretion. ROIs
were drawn separately around the upper and lower poles of the
transplant kidney. The upper pole provides approximately 33% of the
function of the transplant kidney, and the lower pole provides
approximately 67% of the function of the transplant kidney.
In response to Lasix, there is emptying of radiotracer activity from
the lower pole with a T-1/2 of approximately 17 minutes.
Recalculation of T-1/2 including only the lower pole collecting
system with background over the lower pole renal cortex yields T-1/2
of 6 minutes.
Post-void and 15-minute delayed dynamic images reveal gradually
increasing uptake in the transplant kidney upper pole. Visually,
there is no excretion of radiotracer activity into the collecting
system ofthe upper pole.
LAO static images demonstrate mild retention of radiotracer activity
in the inferior pole, with intense retention in the upper pole and
no significant collecting system activity of the upper pole.
IMPRESSION:
1. DIMINISHED BLOOD FLOW TO AND PARENCHYMAL FUNCTION OF THE SUPERIOR
POLE OF THE TRANSPLANT KIDNEY; NO SIGNIFICANT EXCRETION OF TRACER BY
THE TRANSPLANT UPPER POLE OVER 60 MINUTES OF IMAGING. DIFFERENTIAL
WOULD INCLUDE RENOVASCULAR INSULT RESULTING IN DIMINISHED FUNCTION
IN THE UPPER POLE. OBSTRUCTION OF UPPER POLE CALYCES AND COLLECTING
SYSTEM RESULTING IN PARENCHYMAL DYSFUNCTION IS ALSO IN THE
DIFFERENTIAL, ALTHOUGH SPECIFIC URINARY OUTFLOW OBSTRUCTION OF ONLY
THE UPPER POLE OF THE TRANSPLANT KIDNEY SEEMS UNLIKELY.
2. GOOD FLOW AND RELATIVE FUNCTION OF THE TRANSPLANT KIDNEY LOWER
POLE. T-1/2 IN RESPONSE TO LASIX IS 17 MINUTES. WHILE THIS T-1/2 IS
IN THE INTERMEDIATE/INDETERMINATE RANGE, THIS POLE OF THE KIDNEY
DOES NOT VISUALLY APPEAR TO BE OBSTRUCTED.
Note: The transplanted kidney was from a cadaver and contained a
small kidney stone. This stone could be the cause for diminished
function in the upper pole. It is important to note that at the time
of this study her CrCl was 1.7 and on a subsequent visit it had
increased to 2.4. This indicates that the transplant kidney function
continues to deteriorate.
Case study submitted by Beth Avery, PharmD
candidate 2008.
BACK
© 2008 Nuclear Education Online
- Images courtesy of University
of Arkansas for Medical Sciences Dept of Nuclear Medicine.
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