Comparison of glomerular filtration rate (GFR) with Tc-99m-DTPA and tubular extraction rate (TER) with Tc-99m-MAG3 in potential living kidney donors: Feasibility of a one-day protocol

Abstract

Aim Sufficient glomerular filtration rate (GFR) is mandatory in living kidney donors (LKD) before renal transplantation (RT). Guidelines recommend exogenous GFR (e. g. Tc-99m-DTPA) besides estimated GFR by plasma creatinine (eGFR). Tc-99m-MAG3 determines split function and tubular extraction rate (TER). This study evaluated a time-efficient one-day protocol for DTPA and MAG3 in potential LKD.

Methods Retrospective analysis of 82 consecutive potential LKD (female, 52; age, 54 [19–73] a). DTPA GFR (Fleming formula) with blood sampling 169 (147–205) min post injection of 27 (18–59) MBq Tc-99m-DTPA. 199 (181–219) min after DTPA injection, same-day renal scintigraphy with 105 (65–150) MBq MAG3 followed (TER according to Bubeck). Sufficient GFR for RT was defined age- and sex-dependent based on British guidelines, normal TER at 70 % of age-dependent average. In 15 separate potential LKD, a blank blood sample before MAG3 injection allowed estimation of remaining DTPA counts and resulting TER error.

Results Remaining Tc-99m-DTPA blood counts during sampling for MAG3 led to median TER underestimation by 12 (IQR, 8–15) ml/min/1.73 m². Before blood count correction, 16/82 patients had reduced TER despite sufficient GFR_Fleming in 13/16 patients. After correction, TER remained reduced in 9/82 patients who all had sufficient GFR_Fleming. 10/82 patients had insufficient eGFR (CKD-EPI) but sufficient GFR_Fleming. Correlation coefficient for TER and GFR_Fleming was ρ = 0.76, for eGFR and GFR_Fleming ρ = 0.61, and for TER and eGFR ρ = 0.55.

Conclusion A one-day protocol for Tc-99m-DTPA GFR and MAG3 dynamic imaging is feasible. If TER is calculated, the proposed method for blood count correction may be applied. However, relevance of the TER remains questionable due to frequent discordance to GFR.

Zusammenfassung

Ziel Eine ausreichende glomeruläre Filtrationsrate (GFR) vor Nierenspende (RT) ist Voraussetzung für Lebendspender (LKD). Leitlinien empfehlen exogene Methoden der GFR-Bestimmung (z. B. Tc-99m-DTPA) neben der geschätzten GFR aus Plasmakreatinin (eGFR). Tc-99m-MAG3 dient der Bestimmung der getrennten Seitenfunktion und tubulären Extraktionsrate (TER). Diese Studie untersuchte ein zeitsparendes 1-Tages-Protokoll für DTPA und MAG3 bei potenziellen LKD.

Methoden Retrospektive Analyse von 82 konsekutiven potenziellen LKD (Frauen: 52; Alter: 54 (19–73) Jahre). DTPA-GFR (Fleming-Formel) mit Blutentnahmen 169 (147–205) min p. i. von 27 (18–59) MBq-Tc-99m-DTPA. Eine taggleiche Nierenszintigrafie mit 105 (65–150) MBq-MAG3 folgte (TER nach Bubeck). Ausreichende GFR vor RT wurde alters- und geschlechtsabhängig nach britischen Leitlinien definiert, normale TER als ≥ 70 % der Altersnorm. Bei 15 separaten potenziellen LKD erlaubte eine zusätzliche Blutentnahme vor MAG3-Injektion die Abschätzung der verbliebenen DTPA-Counts und des resultierenden TER-Fehlers.

Ergebnisse Verbliebene Tc-99m-DTPA-Counts zur Zeit der MAG3-Blutentnahme bewirkten eine mediane TER-Unterschätzung um 12 (IQR, 8–15) ml/min/1,73 m². Vor Blutcount-Korrektur zeigten 16/82 Patienten eine reduzierte TER trotz ausreichender GFR_Fleming bei 13/16 Patienten. Nach Korrektur blieb die TER bei 9/82 Patienten reduziert, bei jeweils ausreichender GFR_Fleming. 10/82 Patienten hatten eine unzureichende eGFR (CKD-EPI) bei ausreichender GFR_Fleming. Der Korrelationskoeffizient für TER und GFR_Fleming betrug p = 0,76, für eGFR und GFR_Fleming p = 0,61 und für TER und eGFR p = 0,55.

Schlussfolgerung Ein 1-Tages-Protokoll für Tc-99m-DTPA-GFR und MAG3-Nierenszintigrafie ist möglich. Wenn eine TER-Bestimmung beabsichtigt ist, kann die vorgeschlagene Blutcount-Korrektur erfolgen. Jedoch bleibt der Stellenwert der TER aufgrund der häufigen Diskordanz zur GFR fraglich.

Key words

living kidney donor - glomerular filtration rate - tubular extraction rate - Tc-99m-DTPA - Tc-99m-MAG3

Schlüsselwörter

Lebendnierenspende - glomeruläre Filtrationsrate - tubuläre Extraktionsrate - Tc-99m-DTPA - Tc-99m-MAG3

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