Nuclear Medicine in Acute and Chronic Renal Failure
Richard A. Sherman and K w a n g J. Byun
The diagnostic value of renal scintiscans in patients
w i t h acute or chronic renal failure has not been
emphasized o t h e r than for the estimation of renal
size. 13~10IH, eTgallium. ~ ' T c D T P A . glucoheptonate
and DMSA all may be valuable in a v a r i e t y of specific
settings. Acute renal failure due to acute tubular
necrosis, hepatorenal syndrome, acute interstitial
nephritis, cortical necrosis, renal artery embolism, or
acute pyelonephritis may be recognized. Data useful
ENERALLY recognized uses for nuclear
G medicine in nephrology include the assess-
ment of renal blood flow, glomerular filtration
rate, separate kidney function and the evaluation
of patients who have undergone renal transplan-
tation or have hypertension. These topics have
received considerable attention in the literature
(including the current volume of this journal)
and will not be the subject of this review. Nuclear
medicine has less widely appreciated (and less
well documented) uses in the evaluation of acute
and chronic renal failure. Only a limited and
largely anecdotal literature written (not surpris-
ingly) from a radiologic rather than a clinical
perspective is available in this area to guide thee
nephrologist. This report critically reviews the
use of various renal scanning procedures in the
adult patient with acute or chronic renal failure
in an effort to increase awareness of nuclear
medicine's value and perhaps stimulate further
studies in this area.
ASSESSMENT OF RENAL SIZE
The determination of renal size is of consider-
able importance to the nephrologist evaluating a
patient with renal insufficiency. Normal size
suggests recent onset (and potential reversibility)
of the renal disease while small kidneys point
toward chronicity and irreversibility. Large kid-
neys suggest specific diagnoses such as amyloido-
sis or polycystic disease.
Radionuclide imaging has been recommended
for use in determining kidney size '-3 particularly
when plain films are not revealing and intrave-
nous urography is unsuccessful or contraindi-
cated. Because of the delayed transit time of 13'I
orthoiodohippurate (OIH) in renal failure,4
Freeman et al. were successful in using this agent
to obtain a renal image by rectilinear scanning in
18 of 19 patients with advanced renal failure
Seminars in Nuclear Medicine, VoL XII, No. 3 (July), 1982
in t h e diagnosis and management of t h e patient w i t h
obstructive or reflux nephropathy may be obtained.
Radionuclide studies in patients w i t h chronic renal
failure m a y help make apparent such causes as renal
artery stenosis, chronic pyelonephritis or lymphoma-
tous kidney infiltration. Future correlation of scan-
ning results w i t h renal pathology promises to further
expand nuclear m e d i c i n e ' s utility in t h e noninvasive
diagnosis of renal disease.
(mean BUN 96 mg/dl, creatinine 7.6 mg/dl)
and inadequate visualization with ~97Hg chlo-
romerodrin, s While renal size was often inexplic-
ably large despite chronic parenchymal disease,
there was confirmation of this finding by high
dose urography. Other reports confirm the value
of 131l OIH in demonstrating renal size despite
severe renal impairment.6-8 Renal concentration
of OIH occurs with as little as 3% of normal
function?
Because of the excellent imaging characteris-
tics of 99mTC,its various chelates are quite useful
in renal failure. '~ This accounts for the superior-
ity of 99mTCdiethylenetriamine pentaacetic acid
(DTPA) over 197Hg chloromerodrin in imaging
the failing kidney~ despite excretion of the for-
mer wholely by glomerular filtration and the
progressive renal uptake with minimal excretion
of the latter, lz-~4 Reba estimated that renal size
could be determined with 99mTCDTPA in 75% of
patients with BUN over 65 mg/dl.'
In addition to the advantages of carrying the
99mTCmoiety, glucoheptonate (GH) and dimer-
captosuccinic acid (DMSA) are both taken up
and retained by the renal tubules. Although
substantially less GH is retained compared with
DMSA, kidney to background activity is compa-
rable for the two agents and they provide renal
images of similar quality. ~2-'4 The significant
urinary excretion of GH makes possible collect-
ing system visualization, an advantage over
DMSA. Both chelates appear superior to 99mTc
From the Division of Nephrology, Department of Medi-
cine, University of Medicine and Dentistry--Rutgers Medi-
cal School, Piscataway, New Jersey and the Department of
Nuclear Medicine, Albert Einstein College of Medicine,
Bronx, N. Y.
9 1982 by Grune & Stratton. Inc.
0001-2998/82/1203-0005502.00/0
265
266 SHERMAN AND BYUN

DTPA for renal imaging in uremia. Studies
comparing GH and DMSA with each other in
renal failure are not available.
GH scanning produces renal visualization in
all but "very extreme" renal failure. ~5 Assess-
ment of renal size with DMSA was successful in
four of five patients with BUN exceeding 100
mg/dl. Scanning frequently needed to be delayed
for 6-10 hr after injection to allow sufficient
blood clearance to permit renal imaging. 16
A limiting factor in achieving optimal renal
images with 99mTC DMSA in renal failure is
DMSA's slow renal uptake compared with the
short halffife of 99mTc.97Ru DMSA, a long lived
chelate, may eventually offer better renal imag-
ing in patients with advanced renal failure. ~7
Successful renal imaging in uremic patients
may be more likely following hemodialysis when
radionuclides which are concentrated in the
urine are used. 7,s Another factor, particularly for
OIH, is increased renal uptake of radionuclides
possibly due to removal by dialysis of competing
organic anio'as. ~'7"8Renal imaging may be better
shortly after an acute reduction in renal function
(as with acute tubular necrosis) than later after
uremic solutes have accumulated.~'8
Despite considerable success in renal imaging
in patients with azotemia, questions remain as to
the accuracy of size estimates. When isotopic
renal size assessments were compared with surgi-
cal nephrectomy specimens Timmermans found
under or over estimates of more than 15% in 4 of
9 patients. Ultrasound estimates of renal size in
this study differed from true renal size by more
than 15% in only one often cases. ~8
Routine scanning techniques also may under-
estimate renal size because of angulation of the
kidney found in 24 of 62 patients with unilateral
diminution of renal size on 99mTc DTPA or
DMSA imaging. ~9 Lateral scanning of the kid-
neys has been recommended when this possibility
exists. Renal scanning, while not the procedure
of choice, can provide a reasonable estimate of
kidney size despite advanced renal failure. The
99mTC chelates, GH and DMSA, and ]31I OIH
seem best able to produce good renal images
despite minimal kidney function. I23IOIH which
has been reported to be superior to '3'I OIH may,
when generally available, prove to be the most
useful agent in renal failure. 2~
ACUTE RENAL FAILURE
Acute Tubular Necrosis
The diagnosis of acute tubular necrosis
(ATN) usually is based on the clinical picture,
urinalysis and blood and urine chemistries with-
out the necessity for any radiologic or nuclear
procedure. Nuclear medicine procedures have,
however, been reported to be of value in provid-
ing supporting evidence for the diagnosis of
ATN, in recognizing disorders mimicking ATN
and in providing useful prognostic information.

Table 1. Causes of Renal Failure in Which Nuclear Medicine Studies May Be of Value
Disorder Nuclear Medicine Study Typical Findings
Acute tubular necrosis 1311OIH Prompt uptake, delayed excretion
Hepatorenal syndrome 99mTcPertechnetate or DTPA Markedly diminished RBF
Cortical necrosis 9s~l'c Pertechnetate or DTPA Markedly diminished RBF
1311OIH Poor or no visualization
Acute pyelonephritis STGallium Unilateral or bilateral uptake
99"i'c DMSA or GH Cortical defects
Acute interstitial nephritis 67Gallium Bilateral intense uptake
Renal artery embolism 99~-I'c Pertechnetate or DTPA Unilateral or bilateral absence of RBF
98"~1"cDMSA, GH or DTPA Unilateral or bilateral absence of up-
take, diffuse or segmental
Obstructive nephropathy 13~10IH, ~9~i-c DTPA Delayed uptake, prolonged excretion,
pelvic accumulation
Chronic pyelonephritis gg"l'c DMSA, GH Cortical defects
Reflux nephropathy 99"~1"cDMSA, GH Cortical defects
Radionuclide VCU Ureteropelvic reflux
Renal lymphoma eTGallium Bilateral uptake, often nodular
Renal artery stenosis sg"~l'c Pertechnetate, DTPA Markedly diminished RRF, often
asymmetric
~3;IOIH. s ~ ' c DTPA, GH, DMSA Asymmetric renal size
NUCLEAR MEDICINE IN RENAL FAILURE
Only rarely is there difficulty distinguishing
ATN from chronic parenchymal renal disease in
patients with advanced renal failure. On occa-
sion, however, the prompt uptake of 131I OIH
seen in most patients with ATN compared with
the poor, delayed uptake found with advanced
chronic renal failure is a useful diagnostic
point 2'21 (Fig. 1).
Schoutens et al. studied ~3~I OIH scanning in
67 patients with severe renal failure, 35 of whom
had the clinical picture of ATN. 6 The kidneys of
all but 2 of the 35 were adequately visualized.
Both of these patients recovered though one was
left with moderate renal insufficiency. Among 41
patients with "acute or rapidly progressing"
renal failure studied by Staab et al., 14 probably
had ATN. s Only one of the 14 had no renal
uptake of 131IOIH; this patient subsequently had
a "good" recovery. Overall, the absence of renal
uptake in 24 patients in the 2 studies was asso-
ciated in 20 instances with end stage renal dis-
ease or death. It was suggested that the assess-
ment of renal uptake of ~mI OIH in patients with
severe renal failure helped predict recovery of
renal function. 6,s
Further review of the data suggest that the
assessment of renal OIH uptake did not add to
the prognosis based on the clinical diagnosis--
patients with acute renal failure did well while
those with chronic renal failure or renovascular
occlusion did poorly. The poor prognosis of
patients with chronic renal failure and non-
visualization on )a~I OIH scanning was con-
firmed by Sherman and B[aufox who reported
that all 16 patients with this finding required
chronic dialysis within 6 mo of the scan. 22'23
Caution in the interpretation of the O I H scan
in patients with no significant renal function is
necessary. Early images may show splenic activ-
ity while somewhat later images may demon-
strate hepatic activity which can be mistaken for
left and right renal uptake respectively. Early
uptake i s based largely on organ blood flow;
maximum uptake in poorly visualized kidneys
would be expected to be a late occurrence22 (Fig.
2).
Harwood et al. confined their study of the
predictive value of ~31I OIH imaging to patients
with a clinical diagnosis of ATN. 7 After 6 mo the
10 patients with a "prominent" renal uptake had
a mean creatinine clearance of 80 ml/min while
267
the clearance of seven patients with a "faint"
uptake was 39 ml/min and that of seven with no
renal image apparent was 25 ml/min. Three
patients in the no renal image group required
chronic hemodialysis while none did so in the
prominent renal image group. The prognosis of
the three groups could not be determined fully
from clinical and laboratory data alone (Fig. 3).
Cortical necrosis has been suggested as a likely
explanation for the absence of renal OIH uptake
in patients with the clinical diagnosis of ATN. 6
This was indeed the finding in 2 of 3 autopsy
studies in such patients with this finding on renal
scanning. 23The hepatorenal syndrome 6 and renal
arterial occlusion 6"s also have been found in
patients with acute renal failure and no kidney
uptake of ~3~IOIH.
Acute renal failure in the patient with a dis-
secting aneurysm of the aorta may result from
renal arterial involvement or from A T N due to
renal ischemia or the use of radiocontrast agents.
Substantial renal blood flow apparent with 99roTe
DTPA or pertechnetate scanning, or prompt
uptake of 13tI OIH with delayed excretion sug-
gest ATN and obviates the need for more inva-
sive studies.
Renal blood flow in ATN has been shown by
Hollenberg et al. (using a 133Xe washout tech-
nique) to be reduced to approximately one-third
of normal. 24The hepatorenal syndrome, zS"z6corti-
cal necrosis z4"27and renal arterial occlusion z8 may
be confused with ATN clinically but differ
pathophysiologically in that extreme reduction in
renal blood flow is characteristic. This difference
in blood flow may be recognized by qualitative
radionuclide determination of renal blood
flow:9'3~or with a noninvasive 3t-33 or invasive 34'3s
quantitative evaluation.
The "nuclear filtration fraction" has been
advocated by Schlegel and Lang as a diagnostic
aid in acute renal failure. 36 The glomerular fil-
tration rate (using 99mTC DTPA or 99roTe iron
ascorbate) and renal blood flow (using ~3q OIH)
were estimated based on 1-2 min renal uptake of
the radionuclides) 7"3s The "nuclear filtration
fraction" (glomerular filtration rate divided by
renal blood flow) was found to be increased in
ATN, decreased in "pre-renal" states and nor-
mal with postrenal obstruction. Though using
this pseudo-filtration fraction is an intriguing
approach felt by these workers to have a "high
 268
Fig. 1A. See caption on t h e following page.
sensitivity (95%) for identification of A T N " data
adequate to evaluate this claim are not avail-
able.
Acute Pyelonephritis
Impaired renal function due to acute pyelo-
nephritis is unusual but may be found if the
infection is severe, 39 is associated with necrotiz-
ing papillitis, or if it complicates underlying
chronic renal disease. 4~ Before one can attribute
an acute decline in renal function to a urinary
tract infection evidence of renal involvement
(rather than infection of the bladder alone) must
SHERMAN AND BYUN
be present. A typical setting in which this deter-
mination may be valuable is in the patient with
chronic renal failure and an indwelling bladder
catheter who develops fever and an acute decline
in renal function. Nuclear medicine studies may
help differentiate upper from lower tract infec-
tion. Preliminary evidence suggests that renal
imaging with 99mTCDMSA or GH may be useful
for this problem 41 but 67Gahas been more exten-
sively studied.
Hurwitz et al. used 24-hr gallium imaging in 49
patients who had pyelonephritis confirmed or
excluded by conventional testing (including 26
examined by invasive methods). 42Among 25 with
NUCLEAR MEDICINE IN RENAL FAILURE 269

0-3 rain. 131I-Hippuran 6'9 m-rn.

Fig. 1. The typical con-

trasting pattern of 1311 OIH
uptake in ATN and chronic par-
enchymal renal disease is illus-
trated. In ATN, uptake is rapid
and excretion is delayed or
absent. In chronic renal dis-
ease, uptake is poor but defi-
nite urinary activity is usually
present in the bladder. (A}
Acute tubular necrosis in a
renal transplant. ~ T c - D T P A
and 1311OIH studies are shown.
Initially, on day 1, perfusion and
uptake of the radiolabeled or-
thoiodohippurate are both
somewhat diminished but still
present. No significant excre-
tion of the radiolabeled or-
thoiodohippurate into the blad-
der is noted. During the subse-
quent days of study, improve-
ment in perfusion, uptake and
excretion of ~31101H are demon-
strated, suggesting recovery
from acute tubular necrosis. (B)
A 42-yr-old hypertensive male
patient with history of chronic
renal failure (BUN 79 mg/dl,
creatinine 5.3 mg/dl). 1311 OIH
renal scan demonstrates dimin-
ished renal function in both kid-
neys. Four hour delayed study
excludes the evidence of signif-
icant postrenal obstruction.
Note that both kidneys are
smaller than normal and blad-
der activity is definitely pres-
ent.

demonstrated upper tract infection 22 had renal
uptake of gallium while 4 of 24 with lower tract
infection had falsely positive exams. Renal gal-
lium uptake was not normally found at 24 hr by
these workers; this contradicted other reports. 43-45
Differences in imaging techniques are the
most likely explanation for this discrepancy.
Detection of the multiple photopeaks of 67Ga, use
of multiple windows with thick septa, middle or
high-energy collimator and tomographic capa-
bilities all enhance 67Gaimaging. 46 With current
technology renal images may normally be seen as
late as 48 hr after injection. 47 Regardless of
technique, renal gallium uptake which increases
from the 24 to the 48 hr scan, 43is unilateral, focal
or as intense as that of the liver is abnormal. 47
Gallium scanning is a promising, noninvasive
method that may aid in the recognition of renal
functional deterioration due to pyelonephritis. In
addition, the procedure appears useful in localiz-
ing renal infection in patients with chronic renal
failure due to polycystic kidney disease. ~5Its use
270 SHERMAN AND BYUN

Fig. 2. (A) Liver and spleen uptake of 13~101H and m"Tc labeled renal agents in advanced renal failure. Posterior scan of the
kidney w i t h ~1 OIH (top and b o t t o m left) and of the liver w i t h m"Tc-suIfur colloid (bottom right). Renal scan obtained after the
administration of 200 uCi of 13~1OIH and a liver scan after the administration of 2 mCi SS'Tc-Sc. In the 0-3-min exposure
(bottom left), a significant accumulation of radioactivity is apparent in the right upper quadrant, corresponding to the area
occupied by the liver. Some activity can be noted on the left which approximates the region of the spleen and could easily be
mistaken for the left kidney. On the 12-15-min view (top), the activity on the left is essentially cleared but there is still some
suggestion of residual activity on the right which could be mistaken for a right kidney. (From Nephron 25:82-86, 1980.)
( B - - P a r t 1 ) A 70-yr-old w o m a n w i t h history of breast carcinoma became azotemic (BUN 70 mg/dl, creatinine 10 mg/dl). The
patient complained of bilateral flank pain. To assess renal function and evaluate the possibility of obstructive uropathy,
m"Tc-DTPA renal perfusion study and ~311OIH renal scan w e r e performed. Sequential 2-sec images of renal perfusion study
demonstrated early m"TC-DTPA activity in the left renal area (arrow) which subsequently was proven to be a spleen. ( B - - P a r t
2) The spleen (arrow) could be easily mistaken for the left kidney. S'~Tc-DTPA activity in the upper quadrant on dynamic and
early static phase (1-2-rain bottom left) was liver activity which could be mistaken for the right kidney. One hour delayed
S~Tc-DTPA study (top left) reveals somewhat enlarged right kidney. Organ identification is aided by the accompanying sulfur
colloid scan (bottom right). ( B - - P a r t 3) ~S~lOIH renal function study (A-C) reveals no left renal activity and very poor right renal
function. A, right upper quadrant activity is from liver. B and C, liver activity cleared and delayed right renal uptake seen. One
hour delayed m"Tc-DTPA renal scan also demonstrates poor right renal function (D). Within 48 hours, ultrasonographic study
of the kidneys confirmed atrophic left kidney and right hydronephrosis with 2-cm renal cortical thickness.
NUCLEAR MEDICINE IN RENAL FAILURE
Scan
Nonvisualization
Ultrasound
Obstruction
J
J
Bilateral
Normal Size
potential recovery substantial
of renal function to total im-
with surgical pairment of
relief renal function
at 6 months
Fig. 3. Evaluation and prognosis of renal nonvisualization with lall OIH.
is discussed more fully elsewhere in this issue in
the article by Handmaker.
Acute Interstitial Nephritis
Recognition of acute interstitial nephritis
(noninfectious) may be easy when the character-
istic features are present but more difficult when
many of these features are absent and ATN is
easily misdiagnosed. 49 Wood et al. first noted the
intense, diffuse 48-hr uptake of gallium in three
patients with biopsy evidence of this disorder: ~
Linton et al., reporting on nine patients with
acute interstitial nephritis due to drugs,
described the same finding on gallium scanning.
In addition, they studied patients with other
renal disorders including six patients with ATN
in whom there was no uptake of the isotope. They
suggested that gallium scanning may help distin-
guish patients with acute interstitial nephritis
from those with ATN.49
Renal gallium uptake is not uniformly absent
in ATN. George et al. described 12 patients with
renal transplants and ATN whose kidneys accu-
mulated the isotope# l Kumar and Coleman
reported three patients with ATN two of whom
271
Study
No Obstruction
J
Bilateral Asymmetric
Small Size Size
dialysis potential
needed within reversibility -
6 months exclude vascular
occlusion
were renal transplant patients) 2 The extent and
intensity of the renal uptake was not described in
either report. Though ATN is frequently listed as
a cause of renal gallium uptake 15'44other reports
of this observation in patients other than recip-
ients of a renal transplant are scarce. 43
Impaired renal function has also been sug-
gested as a cause of delayed (beyond 24 hr) renal
visualization with gallium 43 but evidence to sup-
port this contention is lacking. The evidence to
date suggests that gallium scanning is a useful
means of differentiating acute interstitial nephri-
tis from ATN, particularly when urinary tract
infection is absent and renal uptake is diffuse and
intense (Fig. 4).
Renal Artery Embolism
Renal artery embolism should be considered
as a cause of acute renal failure particularly in
patients with atrial fibrillation or acute myocar-
dial infarction. Radionuclide studies can play a
major diagnostic role in this disorder.
Early reports on patients with renal artery
embolism noted the good correlation of 99rnTc
pertechnetate flow studies with renal arteriogra-
 272 SHERMAN AND 5YUN

] .............. .....

Fig. 4. (A) A 45-yr-old female patient presented with an acutely rising BUN (71 mg/dl) and creatinine (5.5 mg/dl), Clinical
diagnosis was strongly suspicious for acute interstitial nephritis. Slightly delayed lSll OIH concentration and markedly delayed
excretion is noted in both kidneys. Twenty-four hour renal scan demonstrates significant tracer excretion from the kidneys
making obstruction unlikely. Each view illustrates 3-min sclntiphoto. Renal ultrasonogram showed normal renal size without
obstruction. (B) Posterior view of STGallium-citrate renal scan at 48 hr. reveals substantial radiogallium concentration in both
kidneys.

phy. 29'53Lessman et al. reported on 17 cases with
renal artery embolism 15 of whom had acute
renal failure.54 99mTc pertechnetate perfusion
scanning showed unilateral or bilateral absence
of renal blood flow in nine of ten cases studied
and the remaining patient had bilateral perfusion
defects. In the eight patients who also underwent
angiography the findings were virtually identi-
cal.
Even when renal artery embolism does not
completely interrupt renal blood flow, renal fail-
ure may occur in association with multiple par-
enchymal infarcts. 13zI OIH was diagnostic in
this situation in a patient with endocarditis and
renal failure.6 More recently 99mTC DTPA, 55
99mTCGH 15and 99mTcDMSA 12'13have been used
and advocated for recognition of this problem.
When the diagnosis of acute renal failure due
to renal artery embolism is under consideration,
renal scanning may be of considerable value in
recognizing as well as excluding the diagnosis.6"53
Arteriography may not be necessary unless there
are plans for surgical intervention3'54'56 (Fig. 5).
OBSTRUCTIVE NEPHROPATHY
Isotopic scanning techniques appear suitable
for demonstrating urinary tract obstruction in
patients with relatively normal renal function,s7
Since visualization of the collecting system
depends on glomerular filtration and/or tubular
secretion renal insufficiency must, to a varying
extent, impair the sensitivity of kidney scanning
for recognition of hydronephrosis. Despite this
basic difficulty scanning may be useful in
patients with renal insufficiency and urinary
tract obstruction and has been advocated for
diagnostic use in this setting} '57
When routine studies are inconclusive in the
patient with possible obstructive nephropathy
delayed imaging will often produce useful mor-
NUCLEAR MEDICINE IN RENAL FAILURE 273

Fig. 5. (A) A 74-yr-old man was admitted to the hospi-

tal with a pulsatile abdominal mass. The patient had history
of right nephrectomy for renal calculi performed 24 yr ago.
Retrograde femoral aortogram reveals large aneurysm of
lower abdominal aorta. Solitary left renal artery is visible
(arrow). (B) Scintiphotographic studies w e r e performed for
oliguria which developed after placement of an aorto-iliac
by-pass graft. A, posterior lSTHg chlormerodrin study fails
to reveal any renal activity. S-D, m"Tc-pertechnetate study
fails to show any kidney perfusion. Aortic surgical site is
seen as defect in isotope column (arrow). E-F, 131101H study
fails to reveal renal concentration, suggesting renal artery
occlusion rather than ATN or dehydration, other diagnosis
which were considered. (C) Repeat aortogram shows occlu-
sion of solitary left renal artery (arrow). Surgical clips from
by-pass graft aortic operation are apparent. An embolic
atheromatous plaque was removed at surgery. (From J Urol
105:473-481, 1971.)

phological information. 2'6'57 When substantial
renal insufficiency is present and imaging
beyond 24 hr is contemplated, 1311OIH may be
superior to 99mTC chelates 57 due to its longer
halflife.
Malave et al. studied 56 patients with sus-
pected hydronephrosis, half with renal failure,
using 131IOIH and 99mTc DTPA. 5s Images were
not obtained beyond one hour for DTPA or 30
min for OIH. In 1 I% a false positive diagnosis of
hydronephrosis was made while in 26% the
results were inconclusive as a result of poor renal
uptake of the isotopes. Scanning was felt to be
accurate only with normal or moderately
impaired renal function but was useful regard-
less of the degree of renal impairment in follow-
ing interval changes in the function of the
obstructed kidney.
Absence of renal uptake of 131IOIH in patients
with obstructive nephropathy does not preclude
substantial recovery of kidney function. This
applies to both unilateral 59'6~ and bilateral
obstructive disease. 61
The use of ultrasound to detect urinary tract
obstruction has increased dramatically in recent
years. While highly sensitive in the detection of
hydronephrosis a substantial false positive rate
(26%) has been reported. 62 With improving
274
equipment and diagnostic criteria better specific-
ity has been noted58'63 but the further evaluation
of patients with dilated collecting systems may
present problems if, as with chronic renal fail-
ure, 64 avoidance of intravenous contrast media is
desirable.
Diuretic radionuclide renography may help
differentiate a dilated obstructed collecting sys-
tem from one which is dilated but has no
mechanical obstruction.65~8 Renal retention of
the administered radionuclide occurs with
hydronephrosis regardless of the presence or
absence of mechanical obstruction due to dilu-
tion of the isotope in the large collecting system
volume with a lower isotopic concentration per
unit volume of urine passed into the bladder. The
unobstructed hydronephrotic kidney should
respond to diuretics with an increased urine
volume and radioisotope clearance; the mechani-
cally obstructed kidney is unlikely to respond. 66
This methodology is discussed in detail in the
article on obstructive uropathy in this issue.
In patients with renal failure66this method can
be applied successfully if the collecting system is
adequately visualized and a diuresis achieved.
Measurement of urine volume following the
diuretic injection may be helpful69 as may
increasing the dose of furosemide. While an
obstructive pattern may reflect poor renal func-
tion, a dilated, nonobstructive pattern will still
effectively rule out mechanical urinary tract
obstruction .66
CHRONIC RENAL FAILURE
Chronic Pyelonephritis
Recognition of chronic nonobstructive pyelo-
nephritis in the adult may be difficult since a
positive urine culture and pyuria are nonspecific
and the "classical" changes on urography (caly-
ceal blunting and deformity with depression of
the overlying cortex) are seen most commonly in
childhood as a result of vesicoureteral reflux, v~
Adults with pyelonephritis may have advanced
histologic damage without apparent abnormality
on urography.7! Davies et al. used 19VHg chloro-
merodrin to study 50 patients with the clinical
diagnosis of chronic pyelonephritis and normal
urography.72 Despite the poor image resolution
that was possible with the agent and equipment
used, localized renal defects were seen in 10
patients.
SHERMAN AND BYUN
McAfee reported on 31 patients with chronic
pyelonephritis (seven with renal insufficiency)
who underwent urography and renal scans with
99mTc GH and 131I OIH and had abnormalities in
one of these studies. 73Although the overall sensi-
tivity to renal morphologic abnormalities was
greater with urography than with scanning, focal
parenchymal damage was better seen with
nuclear imaging in eight patients and GH was
more useful than OIH. As might be expected
99mTc DMSA also has been reported to facilitate
assessment of cortical scarring in pyelonephri-
tis.9,15,16
Unlike urography, renal scans can demon-
strate intraparenchymal abnormalities which do
not deform the collecting system or renal outline.
Nuclear imaging may therefore be a useful sup-
plement to urography for detection of renal dam-
age due to chronic pyelonephritis. Active renal
infection may, however, result in scanning
defects which resolve with timefl '72
Chronic pyelonephritis (as well as renovascu-
lar disease and unilateral obstruction) may result
in asymmetric renal damage unlike glomerular
disease or nephrosclerosis which tend to cause
symmetrical dysfunction. Recognition of differ-
ences in radioisotope uptake may, to a minor
extent, aid in recognition of these disorders. 74
Reflux Nephropathy
Reflux nephropathy, recognized as an impor-
tent renal disorder in children, has been increas-
ingly recognized in adults as a cause of hyperten-
sion, proteinuria, and renal failure that may
progress to end-stage renal disease. 75'v6 The
direct radionuclide voiding cystourethrogram
(VCU) (using suprapubic puncture or bladder
catheterization) is useful for the detection and
follow-up of patients with clinically significant
vesicoureteric reflux, vv'v8 Though it is often used
in children to minimize radiation exposure it may
be used in adults.
The intravenous radionuclide VCU is an
attractive noninvasive method for detecting
reflux v9 but, because of the prolonged excretion
of the isotope, is not recommended for use in
patients with renal insufficiency, s~ Recognition
of reflux despite renal failure may be possible
using the computer analysis described for
diuretic radionuclide renography.66
 Fig. 6. (A) A 30-yr-old female with hypertension. Phys-
ical examination revealed bruit in right flank. IVP was
normal and digital radiographic study of the kidneys
appeared normal, m"Tc-GH and 13~1OIH renal scan w e r e
done because of persistent hypertension which was refrac-
tory to therapy. An early dynamic renal study (m"Tc-GH 6 - 8
sec.) demonstrates asymmetry of renal perfusion w i t h
diminished right renal blood f l o w and 2 hr static image
shows reduced right renal size with some segmental loss of
cortex while left kidney shows normal size and contour.
Angiographic study reveals normal left renal artery but
right renal artery demonstrates flbromusuclar dysplasia
(arrow). (B) Transluminal angioplasty was done. Note pre-
operative lS~l OIH renal scan with delayed right renal tracer
concentration and excretion. Cross-over sign compatible
w i t h renovascular disease is seen on renogram curves
between right and left kidney prior to angioplasty. Postop-
erative seventh day :Sll OIH renal scan shows improvement
of right renal function.
 276
Renal Lymphoma
Renal insufficiency is a common complication
of malignant lymphomas and results from hyper-
calcemia, uric acid nephropathy, glomerulopa-
thies, dehydration, urinary tract obstruction,
amyloidosis, or, in 12%-14% of patients, 81 lym-
phomatous infiltration of the kidneys. Gallium
scanning will detect lymphomatous organ
involvement, including that of the kidney, 82 with
a sensitivity of from 30 to more than 75%
depending upon the imaging equipment used
and, possibly, the histologic class of the lympho-
ma.83
Gallium scanning may be of value in evaluat-
ing the patient with lymphoma and renal failure.
A multinodular pattern of renal involvement,
detectable on scanning, 84 is 10 times more com-
mon at autopsy than diffuse involvement,8~ mak-
ing the pattern of gallium uptake useful. Urogra-
phy and ultrasound may be unable to differen-
tiate renal cysts from lymphomatous nodules. 84
More studies of gallium scanning in renal lym-
phoma are needed before the actual value of the
exam can be assessed.
Renal Artery Stenosis
Renal artery stenosis, in addition to its role in
hypertension, is an important, potentially treat-
able cause of renal failure. It has become increas-
ingly recognized that even prolonged vascular
occlusion does not preclude successful repair of
the stenosis with recovery of renal function, ss
As with renal artery embolism, radioisotope
scanning with 99mTCpertechnetate or DTPA has
been used to assess renovascular patency with a
high degree of accuracy. 2s,86 The absence of
perfusion on flow studies is not diagnostic of
complete vascular occlusion but the additional
observation of no uptake of OIH indicates an
essentially nonperfused kidney, g7 More sophisti-
cated techniques that allow noninvasive, quanti-
REFERENCES
1. Reba RC, Poulose KP, Kirchner PT: Radiolabeled
chelates for visualization of kidney function and structure
with emphasison their use in renal insufficiency.SeminNucl
Med 4:151-168, 1974
2. JacobsRP, Laing FC, KorobkinM, et al: Renal failure,
in RosenfieldAT, GlickmanMG, HodsonJ (eds): Diagnostic
Imaging in Renal Disease. New York, Appleton-Century-
Crofts, 1979,pp 299-325
SHERMAN AND BYUN
tative assessment of renal blood flow 31-33 also
may be of value in this setting.
Percutaneous transluminal angioplasty is cur-
rently felt to be indicated for renal failure due to
renal artery stenosis s8 and has been successfully
used in patients with this disorder. 89'9~Radionu-
clide studies may be of benefit in evaluating the
success of "balloon" angioplasty as well in recog-
nizing complications from the procedures (Fig.
6). Born et al. 91 used 99mTCpertechnetate, 131I
OIH and 99mTCDTPA to demonstrate improved
renal function in three patients following angio-
plasty.
Kuhlmann et al. studied eight patients with
renal artery stenosis, hypertension and, in half
the cases, renal insufficiency who were treated
with percutaneous transluminal angioplasty. 92
All those with impaired kidney function
improved with restoration of renal blood flow.
Measurement of renal plasma flow using 13tI
OIH clearances with determination of individual
kidney components utilizing a computer-linked
gamma camera were undertaken prior to and
every 2 mo during the 6-month follow-up period.
Both vascular complications of the angioplasty
(occlusion of a renal artery and the development
of a slight renal artery restenosis) were suspected
on the basis of the isotope studies and confirmed
angiographically. Serial isotopic measurements
of renal plasma flow were felt to provide a good,
noninvasive method for evaluating the effects of
the vascular procedure.
A thorough understanding of the wide variety
of conditions in which radionuclide imaging can
be achieved is essential to its use. In the patient
presenting with renal failure, a planned logical
approach may prove of considerable value to the
clinician in the differential diagnosis and progno-
sis of the patients' illness.
ACKNOWLEDGMENT
The excellentsecretarial assistance of Donna MacGregor
is gratefullyacknowledged.
3. Atkins HL, Freeman LM: The investigation of renal
disease using radionuclides. Postgrad Med J 49:503-516,
1973
4. BlaufoxMD, Conroy M: Measurement of renal mean
transit time of hippuran ~3~Iwith external counting. J Nucl
Biol Med 12:107-116, 1968
5. Freeman LM, Goldman SM, Shaw RK, et al: Kidney
NUCLEAR MEDICINE IN RENAL FAILURE
visualization with ~3q-ortho-iodohippurate in patients with
renal insufficiency. J Nucl Med 10:545-549, 1969
6. Schoutens A, Dupuis F, Toussaint C: ~3q-Hippuran
scanning in severe renal failure. Nephron 9:275-290, 1972
7. Harwood TH, Hiesterman DR, Robinson RG, et al:
Prognosis for recovery of function in acute renal failure. Arch
Intern Med 136:916-919, 1976
8. Staab EV, Hopkins J, Patton DD, et al: The use of
radionuclide studies in the prediction of function in renal
failure. Radiology 106:141-146, 1973
9. O'Reilly PH, Shields RA, Testa H J: Renovascular
hypertension and renal failure, in O'Reilly PH, Shields RA,
Testa HJ (eds): Nuclear Medicine in Urology and Nephrolo-
gy. London, Butterworths, 1979, pp 81-85
10. Chervu LR, Freeman LM, Blaufox MD: Radiophar-
maceuticals for renal studies. Semin Nucl Med 4:3-22, 1974
11. Jakubowski W, Graban W, Licinska I, et al: Compar-
ative investigations of renal scanning agents. Eur J Nucl Med
3:33-39, 1978
12. Kirchner PT, Berman H: Radioisotopic imaging, in
Rosenfield AT, Glickman MG, Hodson J (eds): Diagnostic
Imaging in Renal Disease. New York, Appleton-Century-
Crofts, 1979, pp 63-72
13. Arnold RW, Subramanian G, McAfee JG, et al:
Comparison of 99'~Tc complexes for renal imaging. J Nucl
Med 16:357-367, 1975
14. O'Reilly PH, Shields RA, Testa H J: Radiopharma-
ceuticals, in O'Reilly PH, Shields RA, Tests HJ (eds):
Nuclear Medicine in Urology and Nephrology. London,
Butterworths, 1979, pp 148-152
15. Kahn PC: Renal imaging with radionuclides, ultra-
sound, and computed tomography. Semin Nucl Med 9:43-
57, 1979
16. Handmaker H, Young BW, Lowenstein JM: Clinical
experience with 99"Tc-DMSA (dimercaptosuccinic acid), a
new renal-imaging agent. J Nucl Med 16:28-32, 1975
17. Oster ZH, Som P, Gil MC, et al: 97Ru-DMSA for
delayed renal imaging. Radiology 141 : 185-190, 1981
18. Timmermans L: A comparison of radioisotopic and
ultrasonic scanning of the kidney, in zum Winkel K, Blaufox
MD, Funck-Brentano JL (eds): Radionuclides in Nephrolo-
gy. Stuttgart, Thieme, 1975, pp 101-106
19. Kohn HD, Mostbeck A: Value of additional lateral
scans in renal scintigraphy. Eur J Nucl Med 4:21-25, 1979
20. Herman H J, Lange D, Eisenhut M, et al: Radiation
dose and labeling of hippuran, in Bianchi C, Blaufox MD
(eds): Unilateral Renal Function Studies. Basel, Karger,
1978, pp 100-104
21. Hattner RS, Maltz HE, Holliday MA: Differentiation
of reversible ischemia from end-stage renal failure in
nephrotic children with ~3q-hippurate dynamic scintigraphy.
J Nucl Med 18:438-440, 1977
22. Sherman RA, Blaufox MD: Clinical significance of
nonvisualization with 13tI-Hippuran renal scan, in Hollen-
berg NK, Lange S (eds): Radionuclides in Nephrology.
Stuttgart, Thieme, 1980, pp 235-239
23. Sherman RA, Blaufox MD: Obstructive uropathy in
patients with non-visualization on renal scan. Nephron
25:82-86, 1980
24. Hollenberg NK, Epstein M, Rosen SM, r al: Acute
oliguric renal failure in man: evidence for preferential renal
cortical ischemia. Medicine 17:455-474, 1968
277
25. Epstein M, Berk DP, Hollenberg NK: Renal failure in
the patient with cirrhosis. Am J Med 49:175-185, 1970
26. Hollenberg NK, Mangel R, Fung HYM: Assessment
of intrarenal perfusion with radioxenon: A critical review of
analytical factors and their implications in man. Semin Nucl
Med 6:193-215, 1976
27. Kleinknecht D, Grunfeld JP, Gomez PC, et al: Diag-
nostic procedures and long-term prognosis in bilateral renal
cortical necrosis. Kidney lnt 4:390--400, 1973
28. Bell EG, McAfee JG, Makhuli ZN: Medical imaging
of renal diseases--Suggested indications for different modal-
ities. Semin Nucl Med 11:105-127, 1981
29. Freeman LM, Meng CH, Richter MW, et al: Patency
of major renal vascular pathways demonstrated by rapid
blood flow scintiphotography. J Urol 105:473-481, 1971
30. Hennessy WT, Pollack HM, Banner MP, et al: Radio-
logic evaluation of anuric patient. Urology 18:435-445,
1981
31. Smart R, Trew P, Burke 3, et al: Simplified estimation
of glomerular filtration rate and effective renal plasma flow.
Eur J Nucl Med 6:249-253, 1981
32. van Herk G, de Zeeuw D: Unilateral kidney blood
flow measurement using the S~Rb/8~mKrratio, in Bianchi C,
Blaufox MD (eds): Unilateral renal function studies. Basel,
Karger, 1978, pp 67-72
33. Constable AR, Hussein MM, Albrecht MP, et al.
Renal clearance determined from single plasma samples, in
Hollenberg NK, Lange S (eds): Radionuclides in Nephrolo-
gy. Stuttgart, Thieme, 1980, pp 62~i6
34. Grunfeld JP, Sabto J, Bankir L, et al: Methods for
measurement of renal blood flow in man. Semin Nucl Med
4:39-50, 1974
35. Heidenreich P, Oberdorfer M, Hor G, et al: Estima-
tion of renal blood flow by means of technetium-99m and
xenon-133, in zum Winkel K, Blaufox MD, Funck-Brentano
JL (eds): Radionuclides in Nephrology. Stuttgart, Thieme,
1974, pp 58-66
36. Schlegel JU, Lang EK: Computed radionuclide uro-
gram for assessing acute renal failure. Am J Roentgenol
134:1029-1934, 1980
37. Schlegel JU, Hamway SA: Individual renal plasma
flow determination in 2 minutes. J Urol 116:282-285, 1976
38. Schlegel JU, Halikiopoulos HL, Prima R: Determina-
tion of filtration fraction using the gamma scintillation
camera. J Urol 122:447-450, 1979
39. Cotran RS, Pennington JE: Urinary tract infection,
pyelonephritis, and reflux nephropathy, in Brenner BM,
Rector FC (eds): The Kidney. Philadelphia, Saunders, 1981,
pp 1571-1632
40. Freedman LR: Interstitial renal inflammation, includ-
ing pyelonephritis and urinary tract infection, in Earley LE,
Gottschalk CW (eds): Strauss and Welt's Diseases of the
Kidney. Boston, Little, Brown, 1979, pp 817-876
41. Handmaker H, Young B, Fay R: Nuclear renal imag-
ing in acute pyelonephritis. J Nucl Med 20:623, 1979
42. Hurwitz SR, Kessler WO, Alazraki NP, et al: Gal-
lium-67 imaging to localize urinary-tract infections. Br J
RadioI. 49:156-I 60, 1976
43. Staab EV, McCartney WH: Role of gallium-67 in
inflammatory disease. Semin Nucl Med 8:219-234, 1978
44. Henkin RE: Gallium-67 in the diagnosis of inflamma-
278
tory disease, in Hoffer PB, Bekerman C, Henkin RE (eds):
Gallium-67 Imaging. New York, Wiley, 1978, pp 65-92
45. Larson SM, Hoffer PB: Normal patterns of localiza-
tion, in Hoffer PB, Bekerman C, Henkin RE (eds): Gallium-
67 Imaging. New York, Wiley, 1978, pp 23-38
46. Hoffer PB: Imaging technique, in Hoffer PB, Beker-
man C, Henkin RE (eds): Gallium-67 Imaging. New York,
WiIey, I978, pp 9-2I
47. Hauser MF, Alderson PO: Gallium-67 imaging in
abdominal disease. Semin Nucl Med 8:251-270, 1978
48. Mendex G, Morillo G, Alonso M, et al: Gallium-67
radionuclide imaging in acute pyelonephritis. Am J Roentge-
nol 134:17-22, 1980
49. Linton AL, Clark WF, Driedger AA, et al: Acute
interstitial nephritis due to drugs. Ann Intern Med 93:735-
741, 1980
50. Wood BC, Sharma JN, Germann DR, et al: Gallium
citrate Ga 67 imaging in noninfectious interstitial nephritis.
Arch Intern Med 138:1665-1666, 1978
51. George EA, Codd JE, Newton WT, et al: 67Ga citrate
in renal allograft rejection. Radiology 117:731-733, 1975
52. Kumar B, Coleman RE: Significance of delayed 67Ga
localization in the kidneys. J Nucl Med 17:872-875, 1976
53. Hartenbower DL, Winston MA, Weiss ER, et al: The
scintillation camera in embolic acute renal failure. J Urol
104:799-802, 1970
54. Lessman RK, Johnson SF, Coburn JW, et al: Renal
artery embolism. Ann Intern Med 89:477~,82, 1978
55. Sanders RC, Menon S, Sanders AD: The complemen-
tary uses of nuclear medicine and ultrasound in the kidney. J
Urol 120:521-527, 1978
56. Freeman LM: Rapid blood flow scintiphotographic
studies of renal trauma and infarction, in Blaufox MD,
Funck-Brentano JL (eds): Radionuclides in Nephrology.
New York, Grune & Stratton, 1972, pp 281-287
57. Kirchner PT, James AE, Reba RC, et al: Patterns of
excretion of radioactive chelates in obstructive uropathy.
Radiology 114:655~161, 1975
58. Malave SR, Neiman HL, Spies SM, et al: Diagnosis of
hydronephrosis: Comparison of radionuclide scanning and
sonography. Am J Roentgenot 135:1179-1185, 1980
59. KatuI M J, Wax SH: Evaluation of renal function
during experimental hydronepbrosis by means of the radio-
isotope renogram. Surg Gynecol Obstet 126:563-571, 1968
60. Joekes AM: Obstructive uropathy. Semin Nucl Med
4:187-196, 1974
61. Sherman RA, Blaufox MD: Obstructive uropathy in
patients with nonvisualization on renal scan. Nephron 25:82-
86, 1980
62. Ellenbogen PH, Scheible FW, Talner LB, et al: Sensi-
tivity of gray scale ultrasound in detecting urinary tract
obstruction. Am J Roentgenol 130:731-733, 1978
63. Talner LB, Scheible W, Ellenbogen PH, et al: How
accurate is ultrasonography in detecting hydronephrosis in
azotemic patients ? Urol Radiol 3:1-6, 1981
64. Byrd L, Sherman RL: Radiocontrast-induced acute
renal failure: A clinical and pathophysiologic review. Medi-
cine 58:270-279, 1979
65. O'Reilly PH, Lupton EW, Testa H J, et al: The
diuresis renogram, in Hollenberg NK, Lange S (eds): Radio-
nuclides in Nephrology. Stuttgart, Thieme, 1980, pp 216-
220
SHERMAN AND BYUN
66. Thrall JH, Koff SA, Keyes JW: Diuretic radionuclide
renography and scintigraphy in the differential diagnosis of
hydroureteronephrosis. Semin Nucl Med 11:89-104, 1981
67. O'Reilly PH, Testa H J, Lawson RS, et al: Diuresis
renography in equivocal urinary tract obstruction. Br J Urol
50:76--80, 1978
68. KoffSA, Thrall JH, Keyes JW: Diuretic radionuclide
urography: A non-invasive method for evaluating nephroure-
teral dilatation. J Urol 122:451~154, 1979
69. Koff SA, Thrall JH, Keyes JW: Assessment of
hydroureteronephrosis in children using diuretic radionuelide
urography. J Urol 123:531-534, 1980
70. Hodson C J: The radiological contribution toward the
diagnosis of chronic pyelonephritis. Radiology 88:857-871,
1967
71. Saunders CD, Corriere JN: The inability to diagnose
chronic pyelonephritis on the excretory urogram in adults. J
Urol 111:560--562, 1974
72. Davies ER, Roberts M, Roylance J, et al: The renal
scintigram in pyelonephritis. Clin Radiol 23:370-376, 1972
73. McAfee JG: Radionuclide imaging in the assessment
of primary chronic pyelonephritis~ Radiology 133:203-206,
1979
74. Meldolesi U, Casucci R, Comotti L: An analysis of the
diagnostic contribution of double-radiocompound renogra-
phy. Eur J Nucl Med 2:63-66, 1977
75. Kincaid-Smith P, Becket G J: Reflux nephropathy in
the adult, in Hodson J, Kincaid-Smith P (eds): Reflux
Nephropathy. New York, Masson, 1979, pp 21-28
76. Bailey RR: End-stage reflux nephropathy. Nephron
27:302-306, 1981
77. Blaufox MD, Gurskin A, Sandier P, et al: Radionu-
clide scintigraphy for detection of vesicoureteral reflux in
children. J Pediatr 79:239-246, 1971
78. Conway J J, King LR, Belman AB, et al: Detection of
vesicoureteral reflux with radionuclide cystography. Am J
Roentgenol 115:720-727, 1972
79. Hedman JK, Kempi V, Voss H: Measurement of
vesicoureteral reflux with intravenous 99mTc-DTPA com-
pared to radiographic cystography. Radiology 126:205-208,
1978
80. Conway J J, Betman AB, King LR, et at: Direct and
indirect radionuclide cyslography. J Urol 113:689--693,
1975
81. Richmond J, Sherman RS, Diamond HD, et al: Renal
lesions associated with malignant lymphomas. Am J Med
32:184-206, 1962
82. Frankel RS, Riehman SD, Levenson SM, et al: Renal
localization of gallium-67 citrate. Radiology 114:393-397,
1975
83. Turner DA, Fordham EW, Ali A, et al: Gallium-67
imaging in the management of Hodgkin's disease and other
malignant lymphomas. Semin Nucl Med 8:205-218, 1978
84. Shirkhoda A, Staab EV, Mittelstaedt CA: Renal
lymphoma imaged by ultrasound and gallium-67. Radiology
137:175-180, 1980
85. Gulbrandson RN, Al-Bermani J, Gaspard D J: Suc-
cessful renal revascularization after prolonged nonfunction.
JAMA 238:2522-2523, 1977
86. Benedetti-Valentini F, Massa R, Fiorani P, et al:
Sequential scintigraphy in diagnosis and postoperative stud-
ies of renovascular hypertension, in Bianchi C, Blaufox MD
NUCLEAR MEDICINE IN RENAL FAILURE
(eds): Unilateral Renal Function Studies. Basel, Karger,
1978, pp 89-91
87. Koenigsberg M, Freeman LM, Blaufox MD: Radio-
nuclide and ultrasound evaluation of renal morphology and
function, in Edelman CM (ed): Pediatric Kidney Disease.
Boston, Little, Brown, 1978, pp 236-261
88. Slater EE: Percutaneous transluminal angioplasty of
the renal artery: A hypertensiologist's view. Cardiovasc
Intervent Radiol 3:205-206, 1980
89. Logan AG, Steinhardt MI: Restoration of renal func-
279
tion by unilateral percutaneous transluminal dilatation of
stenosed renal artery. Can Med Assoc J 122:910-912, 1980
90. Schwarten DE: Percutaneous transluminal angio-
plasty of the renal artery. Cardiovasc Intervent Radiol
3:197-206, 1980
91. Born ML, Gerlock A J, Goncharenko V, et al: Radio-
nuclide evaluation of renal artery dilatation. Cardiovasc
Intervent Radiol 4:177-182, 1981
92. Kuhlmann U, Vetter W, Furrer J, et al: Renovascular
hypertension: treatment by percutaneous transluminal dila-
tation. Ann Intern Med 92:1-6, 1980