Pediatric applications of renal nuclear medicine

This review should be regarded as an opinion based on personal experience, clinical and experimental studies, and many discussions with colleagues. It covers the main radionuclide procedures for nephro-urological diseases in children. Glomerular filtration rate can be accurately determined using simplified 2- or 1-blood sample plasma clearance methods. Minor controversies related to the technical aspects of these methods concern principally some correction factors, the quality control, and the normal values in children. However, the main problem is the reluctance of the clinician to apply these methods, despite the accuracy and precision that are higher than with the traditional chemical methods. Interesting indications are early detection of renal impairment, hyperfiltration status, and monitoring of nephrotoxic drugs. Cortical scintigraphy is accepted as a highly sensitive technique for the detection of regional lesions. It accurately reflects the histological changes, and the interobserver reproducibility in reporting is high. Potential technical pitfalls should be recognized, such as the normal variants and the difficulty in differentiating acute lesions from permanent ones or acquired lesions from congenital ones. Although dimercaptosuccinic acid scintigraphy seems to play a minor role in the traditional approach to urinary tract infection, recent studies suggest that this examination might influence the treatment of the acute phase, the indication for chemoprophylaxis and micturating cystography, and the duration of follow-up. New technical developments have been applied recently to the renogram: tracers more appropriate to the young child, early injection of furosemide, late postmicturition and gravity-assisted images and, finally, more objective parameters of renal drainage. Pitfalls mainly are related to the interpretation of drainage on images and curves. Dilated uropathies represent the main indication of the renogram, but the impact of this technique on the management of the child is, in a great number of cases, still a matter of intense controversy. Direct and indirect radionuclide cystography are interesting alternatives to the radiograph technique and should be integrated into the process of diagnosis and follow-up of vesicoureteral reflux.