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Clinical Use

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Practice Guidelines

NEPHROSCAN® (Kit for the preparation of technetium Tc99m succimer injection) is approved as an aid to the scintigraphic evaluation of renal parenchymal disorders in adults, pediatrics and term neonates.

Established clinical practice guidelines recommend the use of Tc99m DMSA for the evaluation of the following renal parenchymal disorders.

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Neonates and Pediatrics1:

  • Detection of permanent renal parenchymal scarring at least six months following an acute urinary tract infection3,4,5
  • Detection of acute pyelonephritis6,7,8
  • Detection of parenchymal damage after trauma9
  • Characterization of structural renal abnormalities: e.g. solitary kidney, duplex kidney, small kidney, dysplastic kidney, horseshoe kidney, and pseudo-horseshoe kidney10,11
  • Detection of ectopic renal tissue, including cross-fused renal ectopia
  • Quantitation of each kidney’s contribution to total renal function (i.e. differential renal function)12
  • Confirmation of non-functional multi-cystic dysplastic kidney13
  • Evaluation of unexplained hypertension when there is clinical suspicion for renal disease such as dysplasia or scarring14,15
  • Evaluation of renal parenchymal function in patients with renovascular hypertension before and after revascularization procedures16
  • Renal parenchymal function regional assessment in patients with complex renal calculi before and after treatment17
  • Surgical decision-making for ureteropelvic junction obstruction (UPJO) or refractory VUR based on differential renal function1
  • Evaluation of renal parenchyma when there is an allergy to iodinated CT contrast, and MRI is unavailable/contraindicated1

Adults2:

  • Acute and chronic renal failure18
  • Unilateral/bilateral renal disease (space-occupying lesions included)12
  • Obstructive uropathy19
  • Renovascular hypertensions18
  • Status post renal transplantation20
  • Pyelonephritis and parenchymal scarring21

References

  1. Vali et al. SNMMI procedure standard/EANM practice guideline on pediatric [99mTc]Tc-DMSA renal cortical scintigraphy: an update. Clin Transl Imaging 10, 173–184 (2022).
  2. Blaufox et al. The SNMMI and EANM practice guideline for renal scintigraphy in adults. Eur J Nucl Med Mol Imaging. 2018
  3. Shaikh et al. Association of renal scarring with number of febrile urinary tract infections in children. JAMA Pediatr. 2019, 173, 949-952
  4. Bush et al. Renal damage detected by DMSA, despite normal renal ultrasound, in children with febrile UTI. J Pediatr Urol. 2015, 11(3):126.e1-7
  5. Muniz et al. The role of renal contour change in the diagnosis of cortical scarring after urinary tract infection. Am J Nucl Med Mol Imaging 2022, 12(1):41-43 
  6. Lavocat et al. Imaging of pyelonephritis. Pediatr Radiol. 1997, 27, 159-165
  7. Jakobsson et al. 99mTechnetium-dimercaptosuccinic acid scan in the diagnosis of acute pyelonephritis in children: relation to clinical and radiological findings. Pediatr Nephrol. 1992, 6(4):328-334
  8. Bar-Sever et al. Pediatric Nephro-Urology: Overview and Updates in Diuretic Renal Scans and Renal Cortical Scintigraphy. Semin Nucl Med, 2022, 52(4):419-431
  9. Overs et al. Evaluation of the management of severe trauma kidney injury and long-term renal function in children. J Trauma Acute Care Surg. 2018, 84(6):951-955.
  10. Marceau-Grimard et al. Dimercaptosuccinic acid scintigraphy vs. ultrasound for renal parenchymal defects in children. Can Urol Assoc J. 2017, 11(8)260–264.
  11. Kwan Kim et al. Clinical Significance of Uptake Difference on DMSA Scintigraphy in Pediatric Urinary Tract Infection. Child Kidney Dis 2016, 20, 63-68
  12. Bair et al. Is there still a need for Tc-99m DMSA renal imaging? Clin Nuc Med. 1995, 20, 18-21
  13. Roach et al. Renal dysplasia in infants: appearance on 99mTc DMSA scintigraphy Pediatr Radiol, 1995, 25, 472-5.
  14. Ahmed et al. Dimercaptosuccinic acid (DMSA) renal scan in the evaluation of hypertension in children. Pediatr Nephrol. 2008; 23, 435-438
  15. Rosen et al. Hypertension in children. Increased efficacy of technetium Tc 99m succimer in screening for renal disease. Am J Dis Child 1985, 139, 173-177
  16. Minty et al. Hypertension in paediatrics: can pre and post-captopril technetium-99m dimercaptosuccinic acid renal scans exclude renovascular disease? Eur J Nucl Med 1993, 20, 699–702.
  17. Mendichovszky et al. Nuclear Medicine in Pediatric Nephro-Urology: An Overview 2017 Seminars in Nuclear Medicine. Semin Nucl Med., 2017, 47, 204-228.
  18. Veenboer et al. Diagnostic accuracy of Tc-99m DMSA scintigraphy and renal ultrasonography for detecting renal scarring and relative function in patients with spinal dysraphism. Neurourol Urodyn. 2015, 34, 513-518
  19. Nijeholt et al. The reliability of Tc-99m-DMSA scintigraphy in obstructive uropathy: is late scanning at 24 hours necessary? Word J Urol. 1986, 3, 253-255
  20. Budihna et al. Relevance of Tc-99m DMSA scintigraphy in renal transplant parenchymal imaging. Clin Nuc Med. 1994, 19, 782-784
  21. Lee et al. Tc-99m dimercaptosuccinic acid (DMSA) renal scintigraphy in patients with acute pyelonephritis. Korean J Intern Med. 1995, 10, 43-47

Acute Pyelonephritis (APN):

At the time of a febrile urinary track infection (UTI), 50 to 91% of patients have acute inflammatory damage to their kidneys.1 Of these patients, at least 50% will go on to have permanent scarring to their kidneys.2

Tc99m-DMSA has a sensitivity for diagnosing APN: sensitivity: 83%, specificity: 78%, positive predictive value (PPV): 85% and negative predictive value (NPV): 77%.3

Renal Scarring:

The incidence of UTIs in children <2 years old is 2.1% for girls and 2.2% for boys4 with 30-50% of these children having recurrent UTIs‡.5 The incidence of renal scarring drastically increases with recurrent UTIs;

No UTIs – 0%,
1 UTI – 2.8% (95%CI, 1.2%-5.8%) after,
2 UTIs – 25.7% (95%CI, 12.5%-43.3%) after, and
3 or more UTIs 28.6% (95% CI, 8.4%-58.1%) after.

 

The odds of scarring similarly increases with more recurrent UTIs, 2 UTIs is 11.8x greater than 1 UTI and 3 or more UTIs is 13.7x greater.6 Children with permanent renal scars are more likely to develop hypertension, proteinuria, urine concentration defects, hyperkalemia, acidosis and chronic kidney disease that can lead to end-stage renal failure, with scars being the fourth most common cause of chronic kidney disease.7

Tc99m-DMSA is more sensitive and specific than ultrasound at diagnosing scars with Tc-99m DMSA having a sensitivity of 85% and specificity of 97% compared to histology in non-clinical studies.8

‡: As per the American Urology Association, recurrent UTIs are defined as two separate culture-proven episodes of acute bacterial cystitis and associated symptoms within six months or three episodes within one year.9

References

  1. Rushton HG and Majd M. Dimercaptosuccinic acid renal scintigraphy for the evaluation of pyelonephritis and scarring: a review of experimental and clinical studies. J Urol. 1992, 148, 1726-1732.
  1. Lin et al.  Acute pyelonephritis and sequalae of renal scar in pediatric first febrile urinary tract infection. Pediatr Nephrol. 2003, 18, 362-365
  1. Hitzel et al. Quantitative analysis of 99mTc-DMSA during acute pyelonephritis for prediction of long-term renal scarring. J Nuc Med. 2004, 45(2), 285-289
  1. Jakobsson B et al. Minimum incidence and diagnostic rate of first urinary tract infection. Pediatrics. 1999, 104(2), 222-226
  1. Roupakias et al. Predictive risk factors in childhood urinary tract infection, vesicoureteral reflux, and renal scarring management. Clin Ped. 2014, 53(12), 1119-1133
  1. Shaikh et al. Association of renal scarring with number of febrile urinary tract infections in children. JAMA Pediatr. 2019, 173, 949-952
  1. Mattoo TK. Vesicoureteral reflux and reflux nephropathy. Adv Chronic Kidney Dis. 2011, 18(5), 348-354
  1. Arnold et al. Detection of renal scarring by DMSA scanning – an experimental study. J Ped Surgery. 1990, 25(4), 391-393.
  2. American Urology Association Website: https://www.auanet.org//guidelines/guidelines/recurrent-uti. Last accessed on 9 February 2022

Indications and Usage: NEPHROSCAN®, after radiolabeling with technetium Tc 99m, is a radioactive diagnostic agent indicated for use as an aid in the scintigraphic evaluation of renal parenchymal disorders in adults and pediatric patients including term neonates.

Important Safety Information:

Hypersensitivity Reactions: Hypersensitivity reactions, including urticaria, rash, pruritus, and erythema have been reported with the use of technetium Tc 99m succimer injection in adults and pediatric patients.