1
|
Wehbi EJ, Davis-Dao CA, Williamson SH, Herndon CDA, Chamberlin JD, Dudley AG, Cannon S, Lockwood GM, Kern NG, Zee RS, Braga LH, Welch V, Chuang KW, McGrath M, Stephany HA, Khoury AE. The conundrum of high-grade hydronephrosis with non-obstructive drainage on diuretic renography. J Pediatr Urol 2024; 20 Suppl 1:S11-S17. [PMID: 38906709 DOI: 10.1016/j.jpurol.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Patients with high grade hydronephrosis (HN) and non-obstructive drainage on mercaptoacetyltriglycine (MAG-3) diuretic renography (renal scans) can pose a dilemma for clinicians. Some patients may progress and require pyeloplasty; however, more clarity is needed on outcomes among these patients. OBJECTIVE Our primary objective was to predict which patients with high-grade HN and non-obstructive renal scan, (defined as T ½ time <20 min) would experience resolution of HN. Our secondary objective was to determine predictors for surgical intervention. STUDY DESIGN Patients with prenatally detected HN were prospectively enrolled from 7 centers from 2007 to 2022. Included patients had a renal scan with T ½<20 min and Society for Fetal Urology (SFU) grade 3 or 4 at last ultrasound (RBUS) prior to renal scan. Primary outcome was resolution of HN defined as SFU grade 1 and anterior posterior diameter of the renal pelvis (APD) < 10 mm on follow-up RBUS. Secondary outcome was pyeloplasty, comparing patients undergoing pyeloplasty with patients followed with serial imaging without resolution. Multivariable logistic regression was used for analysis. RESULTS Of the total 2228 patients, 1311 had isolated HN, 338 patients had a renal scan and 129 met inclusion criteria. Median age at renal scan was 3.1 months, 77% were male and median follow-up was 35 months (IQR 20-49). We found that 22% (29/129) resolved, 42% of patients had pyeloplasty (54/129) and 36% had persistent HN that required follow-up (46/129). Univariate predictors of resolution were age≥3 months at time of renal scan (p = 0.05), T ½ time≤5 min (p = 0.09), SFU grade 3 (p = 0.0009), and APD<20 mm (p = 0.005). Upon multivariable analysis, SFU grade 3 (OR = 4.14, 95% CI: 1.30-13.4, p = 0.02) and APD<20 mm (OR = 6.62, 95% CI: 1.41-31.0, p = 0.02) were significant predictors of resolution. In the analysis of decision for pyeloplasty, SFU grade 4 (OR = 2.40, 95% CI: 1.01-5.71, p = 0.04) and T ½ time on subsequent renal scan of ≥20 min (OR = 5.14, 95% CI: 1.54-17.1, p = 0.008) were the significant predictors. CONCLUSIONS Patients with high grade HN and reassuring renal scan can pose a significant challenge to clinical management. Our results help identify a specific candidate for observation with little risk for progression: the patient with SFU grade 3, APD under 20 mm, T ½ of 5 min or less who was 3 months or older at the time of renal scan. However, many patients may progress to surgery or do not fully resolve and require continued follow-up.
Collapse
Affiliation(s)
- Elias J Wehbi
- Children's Hospital of Orange County, Division of Pediatric Urology, Orange, CA, USA; University of California, Irvine, Department of Urology, Irvine, CA, USA.
| | - Carol A Davis-Dao
- Children's Hospital of Orange County, Division of Pediatric Urology, Orange, CA, USA; University of California, Irvine, Department of Urology, Irvine, CA, USA
| | - Sarah H Williamson
- Children's Hospital of the King's Daughters, Division of Urology, Norfolk, VA, USA
| | - C D Anthony Herndon
- Children's Hospital of Richmond at Virginia Commonwealth University, Department of Urology, Richmond, VA, USA
| | | | - Anne G Dudley
- Division of Urology, Department of Research, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Shannon Cannon
- Department of Urology, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Gina M Lockwood
- Department of Urology, The University of Iowa, Iowa City, IA, USA
| | - Nora G Kern
- University of Virginia, Charlottesville, VA, USA
| | - Rebecca S Zee
- Children's Hospital of Richmond at Virginia Commonwealth University, Department of Urology, Richmond, VA, USA
| | - Luis H Braga
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Valre Welch
- Children's Hospital of Richmond at Virginia Commonwealth University, Department of Urology, Richmond, VA, USA
| | - Kai-Wen Chuang
- Children's Hospital of Orange County, Division of Pediatric Urology, Orange, CA, USA; University of California, Irvine, Department of Urology, Irvine, CA, USA
| | - Melissa McGrath
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Heidi A Stephany
- Children's Hospital of Orange County, Division of Pediatric Urology, Orange, CA, USA; University of California, Irvine, Department of Urology, Irvine, CA, USA
| | - Antoine E Khoury
- Children's Hospital of Orange County, Division of Pediatric Urology, Orange, CA, USA; University of California, Irvine, Department of Urology, Irvine, CA, USA
| |
Collapse
|
2
|
Taylor AT, Fazlur Rahman A, Folks RD, Moncayo V, Savir-Baruch B, Plaxton N, Polsani A, Halkar RK, Dubovsky EV, Garcia EV, Manatunga A. Computer assisted interpretation of Tc-99m mercaptoacetyltriglycine diuretic scintigraphy enhances resident performance. Nucl Med Commun 2023; 44:427-433. [PMID: 37038959 PMCID: PMC10171298 DOI: 10.1097/mnm.0000000000001691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/12/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE iRENEX is a software module that incorporates scintigraphic and clinical data to interpret 99m Tc- mercaptoacetyltriglycine (MAG3) diuretic studies and provide reasons for their conclusions. Our objectives were to compare iRENEX interpretations with those of expert physicians, use iRENEX to evaluate resident performance and determine if iRENEX could improve the diagnostic accuracy of experienced residents. METHODS Baseline and furosemide 99m Tc-MAG3 acquisitions of 50 patients with suspected obstruction (mean age ± SD, 58.7 ± 15.8 years, 60% female) were randomly selected from an archived database and independently interpreted by iRENEX, three expert readers and four nuclear medicine residents with one full year of residency. All raters had access to scintigraphic data and a text file containing clinical information and scored each kidney on a scale from +1.0 to -1.0. Scores ≥0.20 represented obstruction with higher scores indicating greater confidence. Scores +0.19 to -0.19 were indeterminate; scores ≤-0.20 indicated no obstruction. Several months later, residents reinterpreted the studies with access to iRENEX. Receiver operating characteristic (ROC) analysis and concordance correlation coefficient (CCC) quantified agreement. RESULTS The CCC among experts was higher than that among residents, 0.84, versus 0.39, respectively, P < 0.001. When residents reinterpreted the studies with iRENEX, their CCC improved from 0.39 to 0.73, P < 0.001. ROC analysis showed significant improvement in the ability of residents to distinguish between obstructed and non-obstructed kidneys using iRENEX ( P = 0.036). CONCLUSION iRENEX interpretations were comparable to those of experts. iRENEX reduced interobserver variability among experienced residents and led to better agreement between resident and expert interpretations.
Collapse
Affiliation(s)
- Andrew T. Taylor
- Department of Radiology and Imaging Sciences, School of Medicine, Emory University, Atlanta, Georgia
| | | | - Russell D. Folks
- Department of Radiology and Imaging Sciences, School of Medicine, Emory University, Atlanta, Georgia
| | - Valeria Moncayo
- Department of Radiology and Imaging Sciences, School of Medicine, Emory University, Atlanta, Georgia
| | - Bital Savir-Baruch
- Department of Radiology and Imaging Sciences, School of Medicine, Emory University, Atlanta, Georgia
| | | | | | - Raghuveer K. Halkar
- Department of Radiology and Imaging Sciences, School of Medicine, Emory University, Atlanta, Georgia
| | - Eva V. Dubovsky
- Department of Radiology, University of Alabama, Birmingham, Alabama
| | - Ernest V. Garcia
- Department of Radiology and Imaging Sciences, School of Medicine, Emory University, Atlanta, Georgia
| | - Amita Manatunga
- Department of Biostatistics and Bioinformatics, School of Public Health, Emory University, Atlanta Georgia, USA
| |
Collapse
|
3
|
Banks KP, Farrell MB, Peacock JG. Diuretic Renal Scintigraphy Protocol Considerations. J Nucl Med Technol 2022; 50:jnmt.121.263654. [PMID: 35610043 DOI: 10.2967/jnmt.121.263654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/10/2022] [Indexed: 11/16/2022] Open
Abstract
Diuretic renal scintigraphy plays a critical diagnostic role by providing a physiologic means for differentiating between obstructive and nonobstructive hydronephrosis as well as assessing the function of the affected kidney. The exam accuracy is highly dependent upon and benefits from close attention to the protocol. This article reviews kidney anatomy and physiology, patient preparation, available radiopharmaceuticals, diuretic administration, acquisition, processing, quantification, and interpretation criteria.
Collapse
|