99mTc-DTPA肾动态显像检测肾小球滤过率的临床应用评价

目的 以^99mTc-DTPA血浆清除率为标准，评价^99mTc-DTPA肾动态显像检查在检测肾小球滤过率(GFR)中的应用价值。方法 选择慢性肾脏病患者197例，年龄均>18岁，诊断均符合美国NKF-K/DOQI关于慢性肾脏病定义。排除肾功能急性恶化因素、水肿、肢体缺如、心功能不全。记录身高、体重。肘静脉“弹丸”式注射^99mTc-DTPA 111 MBq后即刻行肾动态图像采集120 帧，计算双肾GFR，即Gates法，同时于注射后2、4 h各抽血4 ml，分离血浆1 ml，测量其放射性计数，计算99mTc-DTPA的血浆清除率(双血浆法)，所测数值均用体表面积标准化。按双血浆法所测得的GFR值将患者分成3组:A组 77例，GFR < 30 ml·min^-1·(1.73 m²)^-1；B组 74例， 30 ml·min^-1·(1.73 m²)^-1≤GFR < 90 ml·min^-1·(1.73 m²)^-1；C组 46例，GFR≥90 ml·min^-1·(1.73 m²)^-1。分别行肾动态显像法与双血浆法所测值之间的相关分析。 结果 肾动态显像法及双血浆法所测3组GFR[单位:ml·min^-1·(1.73 m²)^-1]分别为:A组 (27.08±12.14) 比 (17.68±5.66)；B组 (63.18±23.59) 比 (51.95±16.81)； C组 (107.28±27.36) 比 (117.96±24.17)。2者间的相关系数分别为rA=0.286(P=0.012)；rB=0.804(P < 0.01)；rC=0.473(P < 0.01)。结论 99mTc-DTPA肾动态显像检查适用于轻、中度肾功能不全患者GFR的评估，但在重度肾功能不全患者中，其测量结果的准确性有待进一步提高。     

Glomerular filtration rate in children with advanced chronic renal failure: methods of determination and clinical applications

The rationale, significance and pitfalls of currently available methods for the determination of glomerular filtration rates in children with advanced chronic renal diseases are reviewed. Normal renal clearances in infants and children from birth to adulthood are presented. Methods of serial measurements of renal function, especially by the reciprocals of serum creatinine concentrations, are evaluated. They are applied clinically to monitor the effectiveness of conservative and new modalities of treatment, such as dietary supplementation with essential amino acids plus their keto analogues, and to determine that 1,25-dihydroxyvitamin-D3 treatment of renal osteodystrophy does not accelerate the deterioration of renal function in children with chronic renal insufficiency.     

超声造影定量技术与核医学肾图评价肾功能不全的相关研究

目的 评价超声造影定量参数在检测慢性肾功能不全中的应用价值。 方法 以99mTc-DTPA肾动态核素显像检查测得肾小球滤过率（GFR）为标准。以33例临床确诊慢性肾功能不全患者为对象,其中男15例,女18例,平均年龄（43.33±6.78）岁。用PHILIPS iU22超声仪器对所有患者双肾皮质进行实时灰阶超声造影灌注成像,超声造影剂为SonoVue,每侧肾脏使用剂量为1 ml。用QLAB图像分析软件计算感兴趣区域内造影剂回声信号的强度,生成时间-放射性核素强度曲线（TIC）,得到超声造影灌注参数。静脉团注148~222 MBq的99mTc-DTPA后即刻进行肾动态显像,计算双肾GFR。将各个超声造影定量灌注参数值分别与肾动态显像所得GFR值作相关性分析。 结果 慢性肾功能不全患者99mTc-DTPA肾动态显像测得GFR 与超声造影定量参数中的曲线下面积( AUC)、曲线上升支斜率（A）呈正相关,rAUC=0.886（P < 0.05）,rA=0.804（P < 0.05）;而与曲线达峰强度绝对值（DPI）、达峰时间（TTP）、曲线下降支斜率（α）无相关,rDPI=0.021（P > 0.05）,rTTP=0.043（P > 0.05）,rα=0.039（P > 0.05）。 结论 部分超声造影灌注定量参数能反映慢性肾功能不全肾皮质血流灌注改变,与核医学肾图测得的GFR有很好的相关性。     

Acute unilateral obstruction of ureter. Disparity in divided renal function calculated from 131I-hippuran and 99mTc-DTPA renography

Fifteen patients with acute unilateral obstruction of ureter and 30 control patients were studied with simultaneous 131I-Hippuran and 99mTc-DTPA gamma camera renography. In severe outflow obstruction the relative function of the obstructed kidney was higher when calculated with Hippuran than with DTPA. No difference was found in the control subjects. This means that the glomerular filtration rate of an obstructed kidney may be relatively more reduced than the renal blood flow. Therefore, measurement of the single kidney fraction of total glomerular filtration rate has to be calculated with a glomerular filtered tracer, e.g., 99mTc-DTPA.     

Measurement of glomerular filtration rate in ICU patients using 99mTc-DTPA and inulin.

Improved and reliable methods for assessing glomerular filtration rate (GFR) in intensive care patients are needed in light of known deficiencies using creatinine clearance. We compared simultaneous two-hour clearances of inulin (CIn), creatinine (CCr), and 99mTc-diethylenetriaminepentaacetic acid (CDTPA) in 18 medical or surgical intensive care patients (range, 49 to 92 years old) with blood urea nitrogen (BUN) levels greater than 17.9 mmol/liter (0.5 mg/ml), serum creatinine levels greater than 150 mumol/liter (0.02 mg/ml), or estimated Cockcroft clearance less than 60 ml/min. Patients had severe renal dysfunction with average GFR of 35 ml/min (range, 2 to 69 ml/min). CDTPA and CCr correlated significantly with CIn, although CDTPA tended to provide a closer approximation. Cockcroft clearance (32 +/- 4 ml/min) was grossly similar to CDTPA and CIn and correlated significantly, especially when weight was calculated using actual as opposed to ideal body weight. In a subset of 13 patients with CIn less than 30 ml/min, only CDTPA was significantly correlated with CIn. In patients in the intensive care unit, CDTPA provides a rapid, accurate, and inexpensive clinical assessment of GFR, even at very low GFRs.     

Comparison of 99mTc-DTPA renal dynamic imaging with modified MDRD equation for glomerular filtration rate estimation in Chinese patients in different stages of chronic kidney disease.

BACKGROUND: The renal dynamic imaging method (modified Gate's method) with (99m)Tc-diethylene triamine pentaacetic acid ((99m)Tc-DTPA) is simple and less time consuming for glomerular filtration rate (GFR) estimation than other methods. However, its diagnostic performance as a surrogate marker of GFR is questioned increasingly. Recently, the modified Modification of Diet in Renal Disease (MDRD) study equation based on data from Chinese patients of chronic kidney disease (CKD) showed significant performance improvement. In the present study, the renal dynamic imaging methods and the modified abbreviated MDRD equation were compared with the plasma clearance method. METHODS: Four hundred and eighty two patients with CKD were selected. GFR were estimated simultaneously using three methods: (i) modified Gate's method (gGFR); (ii) the modified abbreviated MDRD equation (c-aGFR) and (iii) dual plasma sampling method (rGFR). Using rGFR as the reference method, gGFR and c-aGFR were compared with rGFR in each stage of CKD. RESULTS: Both gGFR and c-aGFR were correlated well with rGFR (r(gGFR) = 0.81 and r(c-aGFR) = 0.90, P < 0.001). In the overall performance, c-aGFR had less bias (849.5 vs 933.1 arbitrary units), higher precision (57 vs 78.4 ml/min/1.73 m(2)) and higher accuracy than gGFR. For gGFR, the 15, 30 and 50% accuracies were 32.4, 56.0 and 79.1%, respectively; for c-aGFR, the corresponding accuracy rose to 43.2%, 75.5% and 90.9%, respectively. In each stage of CKD, the modified abbreviated MDRD equation also outperformed the modified Gate's method in the GFR estimation. CONCLUSION: Our results indicated that the performance of the renal dynamic imaging in total GFR estimation was not better than the modified abbreviated MDRD equation in our patient group, and should not be used as a surrogate marker of GFR, especially in clinical trials. We presume that the dynamic renal imaging methods for estimation of GFR can be improved by using proper reference GFR, more adequate background subtraction and soft-tissue attenuation correction, in a relatively larger sample size.     

Age factor in compensatory hypertrophy of the kidney evaluated by 99mTc-DTPA renography

Unilateral nephrectomy initiates a growth response in the contralateral kidney to compensate for the loss of a renal mass. The events which regulate this process are not very clear. We used a newly developed method, 99mTc-DTPA gamma-camera renography, to evaluate the individual kidney function for detection of the change of it. This method is simple, reliable and requires neither blood nor urine samples. Two groups of rabbits were used in the study. Those of 1.5-2 months of age were taken as the young aged group and those of 2 years of age as the old aged group. Kidney weight, glomerular filtration rate (GFR), and effective renal plasma flow (ERPF) were detected both before and 3 weeks after unilateral nephrectomy. After unilateral nephrectomy in both young and old age groups, the kidney weight increased by 119 and 38%, the GFR by 71 and 44%, and the ERPF by 116 and 35%. We conclude that nephrectomy at a young age where there is fast growth would cause the remaining kidney a compensatory hypertrophy which is much better than that in nephrectomy at an old age. The difference of glomerular filtration rate was less apparent than that of the kidney weight and renal plasma flow in both groups of rabbits.     

99mTc-DTPA肾动态显像在评价活体供肾者肾小球滤过率中的应用

目的 探讨99mTc-DTPA肾动态显像在评价活体肾移植供者肾小球滤过率(GFR)中的应用,并观察GFR水平与供者年龄和性别的相关性.方法 212名候选供者均接受肝肾超声波、肝炎病毒感染以及与受者的血型和组织配型等全面检查,如上述检查符合供肾的一般要求,则进一步行99mTc-DTPA肾动态显像检测候选供者的GFR,如GFR≥1.33 ml/s(1 ml/s=60 ml/min),则认为GFR正常;如1.17 ml/s≤GFR＜1.33 ml/s,则行内生肌酐清除率(CCr)检查,如CCr正常,则认为GFR正常,如CCr异常,则候选供者放弃供肾;如GFR＜1.17 ml/s,则候选供者放弃供肾.供者选取后,应用等级相关系数分析不同性别和不同年龄供者间的GFR水平的差异.结果 212名候选供者中,GFR≥1.33 ml/s者137名;1.17 ml/s≤GFR＜1.33 ml/s者55名,其中31名因CCr异常或其他安全性考虑而放弃供肾;GFR＜1.17 ml/s者20名.共有161名候选供者最终被选择为供者供肾,其中男性105名,女性56名,年龄(42.91±11.90)岁(20～62岁).供肾前,男性和女性供者双肾总的GFR分别为(1.51±0.22)ml/s和(1.45±0.18)ml/s,二者间差异无统计学意义(P＞0.05);不同年龄各组间GFR水平的差异均无统计学意义(P＞0.05),老年(＞55岁)和中青年(≤55岁)供者间GFR水平分别为(1.48±0.22)ml/s和(1.49±0.17)ml/s,二者间差异无统计学意义(P＞0.05).相关性分析显示,供者GFR与其年龄无明显相关性(r=-0.033,P=0.69),男性和女性供者的GFR水平与其年龄也无明显相关性(r=-0.053,P=0.571;r=-0.019,P=0.754).供肾后,所有供者短期内肾功能均恢复至正常水平,未发生肾功能异常和严重并发症.结论 99mTc-DTPA肾动态显像在评价活体肾移植供者GFR中具有较好准确性和可重复性;1.33 ml/s＞GFR≥1.17 ml/s者经严格筛选后可作为供者供肾,且预后良好;供者GFR水平与其年龄和性别间无明显相关性.     

Glomerular filtration rate measurement and estimation in chronic kidney disease

Glomerular filtration rate (GFR) assesses kidney function. GFR is measured by renal clearance techniques; inulin clearance is the gold standard but is not easily measured. Thus, other methods to determine GFR have been utilized. Endogenous creatinine clearance (CrCl) is the most widely used, but creatinine secretion falsely elevates GFR. Cimetidine inhibits creatinine secretion, such that CrCl equals GFR, provided there are no difficulties with bladder emptying. Estimation of GFR from serum creatinine (e.g. Schwartz formula) is useful clinically; however, such formulae have not been updated for enzymatic creatinine autoanalyzers. Cystatin C, a small protein, is produced at a relatively constant rate and is reabsorbed in the proximal tubule. Cystatin C may be more sensitive than creatinine in detecting a reduction in GFR, but further studies are needed to prove this. Single injection (plasma) clearance techniques are the most precise measures of GFR. Iohexol is an exogenous marker that is comparable to inulin and ⁵¹Cr-EDTA and can be measured by high-performance liquid chromatography (HPLC). Our pilot and the Chronic Kidney Disease in Children (CKiD) North American studies show that iohexol can accurately measure GFR using a four-point plasma disappearance curve national studies show that iohexol can accurately measure GFR using a four-point plasma disappearance curve (10, 30, 120, and 300 min) or, in most cases, a two-point disappearance time (120 and 300 min).     

三种肾小球滤过率检测方法与99mTc-DTPA清除率的比较与分析

目的为临床准确评估肾小球滤过率（GFR）提供一定依据。方法对101例各种慢性肾脏病患者,外周静脉注射非离子型造影剂碘海醇（iohexol）5ml,4h后取血2ml,用高效液相色谱（HPLC）法检测血浆iohexol浓度。运用数字模型计算血浆iohexol清除率（iohexol-GFR）。同步检测Scr及^99mTc—DTPA清除率（^99mTc—GFR）。应用Cockcroft—Gait（CG）、肾脏病膳食改良试验（MDRD）公式计算Ccr、GFR。以^99mTc—GFR为标准,运用相关回归分析及受试者工作曲线（ROC）对上述指标进行比较。结果慢性肾脏病第1期至第5期,iohexol—GFR与^99mTc-GFR相关系数r分别为0．87、0．89、0．88、0．86、0．87（P均〈0．01）;iohexol—GFR在ROC曲线下面积平均为0．97。MDRD—GFR与^99mTc—GFR相关系数r分别为0．80、0．75、0．71、0．67、0．56（P均〈0．01）,MDRD—GFR在ROC曲线下面积平均为0．82。CG—Ccr与^99mTc—GFR相关系数r分别为0．76、0．67、0．62、0．60、0．53（P均〈0．05）,CG—Ccr在ROC曲线下面积平均为0-82。结论iohexol—GFR检测GFR的准确性优于MDRD—GFR、CG—Ccr,值得推广应用。在无检测条件的情况下,CG、MDRD公式不失为衡量GFR的良好指标。     

Computer processed 99mTc-DTPA studies of renal allotransplants.

In order to refine the diagnostic possibilities of the radionuclide renal study in transplanted patients and to compensate for the nonspecificity of the 131I-hippuran study in some situation, 99mTc-DTPA WAS USED SIMULTANEOUSLY FOR IMAGING AND TIME-ACTIVITY CURVES. For these curves to be significant, appropriate background subtraction had to be made with a simple computer-processing method. The results obtained have shown that it is possible to distinguish marked acute tubular necrosis from milder degrees, thus affording a prognostic index in the immediate postoperative period, when the hippuran data are often nonspecific. Further, the diagnosis and follow-up of acute rejection episodes can be improved by the DTPA processed curves. Although these curves when examined individually do not show a specific pattern for rejection, they may reveal striking evolutionary changes when compared to the previous studies, even when the hippuran curves are unchanged. The physiologic basis for the differences between the two time-activity curves may be related to the differential handling of the two radiopharmaceuticals by the kidney.     

Inaccuracies in estimated glomerular filtration rate in one Australian renal centre

Background: Early identification of true renal disease (glomerular filtration rate (GFR) < 60 mL/min) results in better patient outcomes. There is now routine reporting in Australia of estimated GFR (eGFR) in all patients over age 18 who have serum creatinine measured, calculated by the Modification of Diet in Renal Disease (MDRD) formula, which was validated in an American Caucasian cohort. Significant clinical decisions and prognosis are often made on the basis of this calculation. Aim: To assess the accuracy of three estimates of GFR in an Australian population by comparing eGFR obtained by the abbreviated MDRD (aMDRD), Cockcroft–Gault corrected for body surface area (BSA) (CG) and Chronic Kidney Disease Epidemiology (CKD‐Epi) formulae with a gold standard, isotopic ⁵¹Cr‐ethylenediaminetetra‐acetic acid (⁵¹Cr‐EDTA) GFR. Methods: Patients referred with an eGFR of <60 mL/min reported by the aMDRD formula underwent isotopic measurement of GFR (over 4 h) and had eGFR calculated using CG corrected for BSA, aMDRD and CKD‐Epi formulae. Data were analysed using Bland–Altman plots and regression analysis to compare methods; bias, precision and the proportion of patients correctly stratified by stage of chronic kidney disease (CKD) were also compared according to the three estimates of GFR, using ⁵¹Cr‐EDTA GFR as the gold standard. Results: A total of 139 patients were recruited (female 45%), mean age 64 years and mean serum creatinine 212 µmol/L. The mean GFR (SD) (mL/min per m²) for isotopic, CG, aMDRD and CKD‐Epi were 47 (28), 37 (20), 32 (17) and 33 (18) (P = 0.001). CG (57%) was more likely to correctly stage CKD than aMDRD (37%) or CKD‐Epi (37%), and absolute bias was significantly lower using CG than either other method (P = 0.001). Conclusion: In this small Australian population the CG formula corrected for BSA agreed more closely with isotopic GFR and correctly staged patients with CKD more often than the aMDRD or CKD‐Epi formulae. It is important that each renal Unit considers the accuracy of estimates of GFR according to their population demographics.     

Evaluation of obstructive uropathy in children. 99mTc-DTPA renography studies under conditions of maximal diuresis

Renographic studies under standardised conditions of maximal diuresis provoked by hypotonic saline infusion and frusemide were used in 17 patients with dilatation of the upper urinary tract in order to distinguish between obstructed and non-obstructed urinary tracts. Of the six patients who were obstructed on clinical and X-ray evidence only three showed an obstructed pattern on the renographic curves after maximal diuresis. After operation these three patients showed improvement in both renographic curve and functional images of the renal parenchyma. A new method of identifying the parenchymal area is described.     

^99mTc—DTPA测定肾小球滤过率在移植肾活体供体中的应用价值

目的制定^99mTc—DTPA测定肾小球滤过率（GFR）在不同年龄组中的正常参考范围,评价其在移植。肾活体供体中的临床价值。方法300例移植肾供体行肾动态显像,应用Gates法计算GFR,统计分析GFR正常参考范围及不同年龄组GFR正常参考范围,分析其与性别、年龄、身高体重指数的关系。结果300例供肾者左肾、右肾及总肾的GFR为（49．25±10．34）mL／min、（49．27±9．69）mL／min及（98．52±19．03）mL／min;〈50岁者的GFR显著高于≥50岁者,〈50岁或≥50岁,各年龄组间GFR无显著性差异;Logistic回归分析表明GFR仅与年龄相关。始论：^99mTc-DTPA肾动态显像测定GFR方法简便、可靠,可以反映分肾功能、评估尿路排泄情况,对筛选移植肾供体具有一定价值。     

Longitudinal analysis of performance of estimated glomerular filtration rate as renal function declines in chronic kidney disease

Background. Numerous studies have assessed the accuracy of equationsestimating glomerular filtration rate (eGFR) from serum creatininein individuals with chronic kidney disease (CKD) in cross-sectionalstudies. Limited literature exists, however, on the consistencyof performance of these equations in longitudinal studies asrenal function declines. Methods. Radionucleotide-measured GFR from 155 predialysis patientswith stage 3–5 CKD was compared with eGFR derived fromfour equations [6-variable Modification of Diet in Renal Disease(6-MDRD), 4-variable MDRD (4-MDRD), Cockcroft–Gault (CG)and Cockcroft–Gault equations corrected for body surfacearea (CGC)] at baseline, 12 and 24 months. Bias (differencebetween eGFR and measured GFR) was used as a measure of performance.Restricted Maximum Likelihood (REML) models were used to identifyvariables potentially affecting the performance of estimatingequations across time. Results. Mean measured GFR (±SD) at baseline, 12 and24 months was 25.9 ± 10.7, 23.1 ± 10.6 and 20.3± 10.1 mL/min/1.73 m², respectively. There was a statisticallysignificant negative association between bias and GFR for allfour estimates (range: –0.76 to –0.71, P < 0.001for all), indicating worsening underestimation and overestimationat higher and lower GFR, respectively. This negative associationsignificantly reduced over the 24 months (P < 0.001); however,this was largely due to persistent underestimation of eGFR fromindividuals with GFR >50 mL/min/1.73 m². For those with abaseline GFR <50 mL/min/1.73 m², the change in bias for anyof the four equations over 24 months was 1.1 mL/min/1.73 m²,suggesting relatively preserved performance with time. The MDRDequations showed a sustained advantage in estimating renal functionthat was more evident as GFR declined. Conclusion. GFR estimates are inexpensive and show an acceptablelongitudinal performance for monitoring CKD patients with GFR<50 mL/min/1.73 m². Inaccuracies appear more substantialabove this level of GFR, and care with interpretation is required.     

Abnormal 99mTechnetium-tin-pyrophosphate bone scans in chronic renal failure.

A high incidence of abnormal 99mTechnetium-tin-pyrophosphate (99mTcPPi) is reported in a population of chronic renal failure patients. Using the 5 hour bone to soft tissue ratio as a quantitative index of increased uptake, 78% of 45 long-term dialysis patients and a similar proportion of non-dialyzed chronic renal failure patients were found to have increased uptakes. In animal studies using a uremic model, similar increased uptakes of 99mTcPPi was found with evidence of increased vascularity as reflected by red cell or plasma volumes in the bone or by the uptake of concomitantly administered 45Ca. The evidence suggests that the abnormal bone scans reflect abnormalities in collagen metabolism that occurs in the uremic state and that 99mTcPPi scans are useful in the diagnosis and management of renal osteodystrophy.     

应用~(99m)Tc-DTPA摄取率测定肾小球滤过率与传统方法计算肌酐清除率的比较

目的 :评估在中国慢性肾脏病人中应用肌酐清除率 (Ccr)估计肾小球滤过率 (GFR)的有效性 ,并介绍由ToTo等人推导出的一条计算Ccr的新公式 (我们简称ToToes’公式 )。方法 :研究中国慢性肾脏病人 10 0例 (男 5 0例 ,女 5 0例 )。应用99mTc-DTPA摄取法 (Gates法 )测定GFR ;采用三种方法根据血肌酐 (Scr)计算Ccr :2 4hCcr(2 4hCcr) ,Cockcroft-Gault公式计算Ccr(Ccr -CG)及用ToToes’公式计算Ccr(Ccr -TT) ;然后将Ccr与测定的GFR比较 ,其准确度用二者的差值 (△GFR =GFR -Ccr)和比值 (GFRratio =Ccr/GFR)来评估 ,可靠性用决定系数r2 和平方误差的联合平方根 (CRMSE)来评估。结果 :男性组 :(1)△GFR :Ccr -CG≈CCR -T <2 4hCcr ;(2 )GFRratio :Ccr -CG≈Ccr -TT >2 4hCcr ;(3)r2 :Ccr -CG >Ccr -TT >2 4hCcr ;(4 )CRMSE :Ccr -CG≈Ccr -TT <2 4hCcr。女性组 :(1)△GFR :Ccr-TT Ccr -CG >2 4hCcr;(3)r2 :Ccr -CG >Ccr -CG≈ 2 4hCcr;(4 )CRMSE :Ccr-TT 相似文献