MAG3 diuretic renography

A report skeleton for 99mTc-MAG3 diuretic renography in suspected upper urinary tract obstruction. It follows the reporting elements of the joint SNMMI/EANM adult guidelines and adds a paediatric block based on the joint 2018 paediatric guideline.

Based on: SNMMI procedure standard/EANM practice guideline for diuretic renal scintigraphy in adults (Taylor 2018); SNMMI/EANM renal scintigraphy guideline in adults (Blaufox 2018); SNMMI/EANM diuresis renography guideline in infants and children (Majd 2018)

99mTc-MAG3 DIURETIC RENOGRAPHY

CLINICAL INDICATION:
  [Suspected pelviureteric junction / ureteric obstruction / hydronephrosis on ultrasound / follow-up after pyeloplasty, stent or nephrostomy]
  Clinical question: [ ]
  Serum creatinine [ ] on [date] / no recent creatinine available
  Relevant imaging: [ultrasound / CT / MRI, date]; urological procedures: [ ]
  Medication affecting renal haemodynamics or transit: [diuretic / ACE inhibitor / ARB / calcium-channel blocker / NSAID / none]

TECHNIQUE:
  Hydration: [oral / IV, volume, timing]; voided before acquisition: [yes / no]; bladder catheter: [yes / no]
  99mTc-MAG3 [ ] MBq IV bolus, [site]; bolus quality [good / extravasation]
  Acquisition: [supine / seated], posterior view, dynamic [ ] min
  Furosemide: [ ] mg IV (0.5 mg/kg or 40 mg in adults; 1 mg/kg, maximum 40 mg, in children) at [F−15 / F0 / F+10 / F+20 / other]
  Post-void image after standing upright, same position and frame duration as the last dynamic frame, at [ ] min
  Voided volume [ ] mL; side effects: [none / flank pain / [ ]]

COMPARISON:
  [Prior renogram dated [ ] / none]

FINDINGS:
  Study quality: [adequate / limited by motion or extravasation]
  Kidneys: [position, size, shape, symmetry, defects]
  Image series: [symmetrical, prompt uptake and prompt excretion / delayed cortical transit / retention in the collecting system on the [right / left]]
  Relative function (1–2 / 1–2.5 / 2–3 min, or Rutland-Patlak): right [ ]%, left [ ]% (normal range [ ])
  Time to peak (Tmax): right [ ] min, left [ ] min
  20 min / maximum count ratio (cortical ROI): right [ ], left [ ]
  Response to furosemide: [prompt drainage / partial drainage / no drainage; curve [falling / flat / rising]]
  Drainage half-time (method [ ]): right [ ] min, left [ ] min
  Post-void image: [collecting system largely cleared / residual activity on the [side]]; post-void/max ratio [ ]
  Bladder: [ ]

PAEDIATRIC STUDY (if applicable):
  Activity scaled to weight using the [EANM / SNMMI] paediatric dosage table
  Relative function from the summed second-minute image (60–120 s) [or integral / Rutland-Patlak method]
  NORA: right [ ], left [ ] (1-min counts at end of imaging as a proportion of second-minute counts)
  Gravity-assisted (upright) and post-void images: [ ]

IMPRESSION:
  1. Relative function: right [ ]%, left [ ]% [(normal / reduced on the [side])]
  2. [No evidence of obstruction / drainage impaired on the [side] without evidence of obstruction after post-void imaging / findings consistent with obstruction on the [side]: flat or rising curve with little or no clearance on upright post-void images / equivocal]
  3. [Change from prior study; recommendation]

Before you sign

• Measure relative function early, before activity leaves the parenchyma: 1–2, 1–2.5 or 2–3 min, or with the Rutland-Patlak plot. In children, use the summed second minute (60–120 s).
• The drainage half-time is not standardised. Name the method, and do not decide obstruction on T½ alone. A T½ under 10 min generally excludes obstruction.
• A post-void image after standing upright, in the same position and frame duration, is essential. Parameters that include it separate obstructed, equivocal and non-obstructed kidneys better than T½ does.
• In children, call a high likelihood of critical obstruction only when the drainage curve is flat or rising and there is little or no clearance on upright images. No single parameter should be read in isolation.
• For MAG3 with cortical regions, a 20 min/maximum ratio above 0.35 suggests abnormal renal function; the mean normal value is 0.19.
• Record hydration, voiding, bladder catheter, voided volume, furosemide dose and timing, and any flank pain, because these change drainage. Avoid the term "partial obstruction".
• Give relative function with its normal range and limit transit parameters to one or two, each with its normal range.

Sources

1. Taylor AT, Brandon DC, de Palma D, et al. SNMMI procedure standard/EANM practice guideline for diuretic renal scintigraphy in adults with suspected upper urinary tract obstruction 1.0. Semin Nucl Med. 2018;48:377–90.
2. Blaufox MD, De Palma D, Taylor A, et al. The SNMMI and EANM practice guideline for renal scintigraphy in adults. Eur J Nucl Med Mol Imaging. 2018;45:2218–28.
3. Majd M, Bar-Sever Z, Santos AI, De Palma D. The SNMMI and EANM procedural guidelines for diuresis renography in infants and children. J Nucl Med. 2018;59:1636–40.

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