Serial radiohippurate renal scintiphotography

Serial radiohippurate renal scintiphotography Leonard Rosenthall, m.d., N. David Greyson, Robert H. Martin, m.d., Montreal

m.d.

and

222 Summary: The results of serial radiohippurate scintiphotography in dis¬ renal diseases are patients are analyzed. The findings in various the cussed and compared with those obtained from excretory urogram, BUN, serum creatinine and creatinine clearance.

carried out with the subject in a horizontal prone or decubitus posi¬ tion, with the renal area of the back against the dctector head of the gamma camera (Pho/Gamma,

Nuclcar-Chicago). Following direct

intravenous in¬

Since the original description of changing pattern of distribution of jection of 200 ftc. or in some cases the Diodrast renogram in rabbits 131IH in the kidney could be re¬ of severe renal failure 400 fic. of by Taplin et al.,10 the concept of corded on serial scintiphotographs. 131IH, serial three- to five-minute renal function evaluation by exter¬ In 1966 Burke and Halko1 de¬ scintiphotographs are obtained nal monitoring devices has been scribed the use of the gamma over a period of half an hour, camera for renal imaging with and then additional pictures at one widely accepted. Tubis and his co-workers11 de¬ mIH in diseases in which renal hour, two hours and longer if re¬ veloped 131I-labelled ortho-iodohip- transit was prolonged, and Rosen¬of quired. In some cases patients were followed up for more than three puric acid (,31IH)in 1960 and used thall9 reported the superiority it as a tracer agent.0 This proved to 131IH renal scintiphotography in days. be superior to other radiopharma- renal failure over radiochlormeroIn reviewing these cases all ceuticals because of its rapid se¬ drin imaging and intravenous pye- pertinent history, laboratory data, cretion by the proximal renal lography. Other reports have fol¬ radiographic findings and biopsy tubules without binding,7 and its lowed.2 or autopsy data were evaluated. insignificant accumulation in other Since 1965 we have been using The final interpretation of the organs.9 The dual probe tech¬ the technique of kidney imaging radionuclide study was made by with 131IH is now widely with radioiodinated hippurate by one of the authors (L.R.) without nique 12used.3' 13 serial scintiphotographs (131IH benefit of history, and then correThe renogram provides compar¬ series). Conventional reno grams lated with other information. Postison of individual renal function are still used in the investigation renal obstruction was deduced in the form of graphs, but because of hypertension and when renal when there was a persistent visuali¬ of the swift clearance of 131IH its dysfunction is slight. The 131IH zation of the pelvicalyceal system use in renal imaging has been series is employed if it is anticipat¬ for more than one hour, and an limited, although rectilinear scan- ed that the renogram will be ab¬ interpretation of a dilated ureter ners have been used with some normal. In some cases where the was made when the structure was success.4 It is only with the de¬ renogram curve fails to fall, gamma seen consistently. Failure to demon¬ follow¬ strate the pelvicalyceal system in velopment of rapid imaging de¬ camera studies are used as aretained vices, such as the gamma ray up to localize the areas of the presence of a prolonged transit scintillation camera, that the activity. time indicated pre-renal or intrareour exper¬ outlines This paper nal disease. From the Montreal General Hospital, ience with this technique in 222 Montreal, Quebec. The various categories of disease Leonard Rosenthall, m.d., Director, from November 1965 to entities studied are shown in Table Division of Nuclear Medicine, Montreal patients General Hospital. June 1969. I. There was a total of 222 patients, N. David Greyson, m.d., Resident in Nu¬ clear Medicine. Robert H. Martin, m.d., Resident in Nu¬ ranging in age from 12 to 92 years. clear Medicine. Method and material The pediatric age group is under¬ Reprint requests to: Dr. Leonard Rosen¬ thall, Division of Nuclear Medicine, Mont¬ real General Hospital, Montreal 109, Quebec.

Patients

were

not

Many pa¬ given any special going a separate analysis. examinations.

preparation. The examination 1266 C.M.A. JOURNAL/DECEMBER 5, 1970/VOL. 103

was

tients had

multiple

Results related to pathology and discussion

Normal

cases) and acute (seven cases).

tubular necrosis

In renal failure the residual func¬

tion could often be demonstrated

Because of our selection of cases better and sooner with 131IH than with anticipated renal pathology from the contrast based on clinical evaluation, only material. A radiographic case in point is a pa¬ nine of 222 patients could be con¬ tient with a chronic glomerulone¬ sidered completely normal bilater¬ phritis who had a BUN of 84 mg., ally. serum creatinine of 7 mg. and It is important that the renal creatinine clearance of 10.5 ml. per scintiphotographs should be com¬ minute. The drip infusion pyelopared with the IVP when avail¬ gram first showed a nephrogram able. An extrarenal, or "baggy", at eight hours, whereas the kidneys pelvis may appear to drain slowly were with 131IH in 25 min¬ owing to its large reservoir, but utes, imaged and obstruction was ruled these cases demonstrate a normal out because drainage proceeded rate of concentration and virtually without evidence of a dilated upper complete drainage by one hour. 2.Renal failure due to renovascollecting system. Another example FIG. cular disease. The 60-year-old man had severe left renal artery stenosis and right was a patient with acute renal fail¬ nephrosclerosis. The left kidney was not Congenital anomalies ure due to tubular necrosis second¬ visualized with 203Hg chlormerodrin 1), nor was there concentration The diagnoses of ectopic, duplex, ary to hypotension who had non- of(Frame radiopaque material on the left side with IVP. A 131IH series (Frames 2, 3 pelvic and polycystic kidneys are functioning kidneys on the IVP, and tioning and 4) showed the presence of a func¬ left kidney as early as 10 min¬ easily made. In particular, the underwent retrograde pyelography utes, but it was more distinctly imaged at 40 to 50 minutes (Frame 4). Although function and drainage of a pelvic to rule out obstruction. The 131IH the right kidney possesses better func¬ some impairment is present as there kidney, in spite of its juxtaposition series visualized the kidneys and tion, is parenchymal retention at 50 minutes. to the urinary bladder, is readily demonstrated the absence of ob¬ The absence of a dilated upper collect¬ system rules out obstructive uro¬ assessed. This can be difficult with structive uropathy in spite of a ing pathy. the 131IH renogram. Of the four BUN of 83 rising to 180 mg. and a cases of polycystic kidneys, two serum creatinine of 3.5 rising to factor in the did not have azotemia and the 6.7 mg. Ureteric instrumentation is the determining of choice The kidneys management. focal areas of function were better not without complication and could were not with 131IH in imaged appreciated in the first three min¬ have been avoided. several cases with a high BUN and utes of the radionuclide study than Twenty-seven out of 63 patients poor creatinine clearance, but from the IVP. did not have an IVP, whereas the very the accumulation of activity in the others had double-dose IVP's (50 Renal failure without obstruction ml. Renografin-60), drip infusion urinary bladder indicated that at A total of 63 cases of severe azo¬ pyelograms, or retrograde pyelotemia due to renal and prerenal grams to rule out obstruction. A factors were studied. Scintigrams of prolonged transit time of 131IH two cases are shown in Figs. 1 and and a failure to visualize a dilated 2. The most common diagnoses pelvicalyceal system was the diswere chronic glomerulonephritis tinguishing feature vis-a-vis ob¬ structive uropathy. This was often (13 cases), Kimmelstiel-Wilson diabetic nephrosclerosis (seven

FIG.

3 Scintigram of a 73-year-old who had obstructive renal failure secondary to carcinoma of the urinary

man

FIG. 1.A case of pre-renal failure in a 26-year-old woman. The patient was dia¬ betic with acidosis and marked dehydration. The BUN was recorded at 96 mg. per 100 ml. isiih series exhibits prompt appearance of activity in both kidneys at 0 to 5 minutes, but there is also a pro¬ longed transit time as most of the radiopharmaceutical is still in the parenchyma of the kidneys after one hour. There is no evidence of a dilated pelvicalyceal system to indicate obstructive uropathy. Accumulation of activity in the urinary bladder commences at 20 minutes.

bladder. The BUN was 168 mg. per 100 ml. and serum creatinine 12.1 mg. per 100 ml. drip infusion IVP demonstrated hydro¬ nephrosis of the right kidney at three hours and no function on the left. The kidneys did not image with radiochlormerodrin (Frame 1). At 15 minutes a viable right kidney was depicted with 131IH (Frame 2), and at two hours (Frame 3) the left kidney was apparent. A dilated right ureter was recorded at two and 24 hours (Frames 3 and 4). A right nephrostomy subsequently resulted in some improvement in function. A

C.M.A. JOURNAL/DECEMBER 5, 1970/VOL. 103 1267

TABLEH Predictive use of 131M series in obstructive uropathy

Case No. 1

Resvlt of preoperative IVP Non-functioning right kidney Non-functioning left

Pathology Postoperative follow-up Findings at operation Non-functioning right Lymphosarcoma ureter Ischemic atrophy obstructing right kidney left Ischemic atrophy and Non-functioning Ureteropelvic junction ulcerative obstruction pyelitis kidney kidney Non-functioning right Some function of right No surgery. Irradia¬ Improved function tion for lymphosarcoma after irradiation kidney; hydronephro¬ kidney; bilateral sis left kidney hydronephrosis Atrophy due to Non-functioning right Non-functioning right Right ureteric calculus chronic obstruction kidney kidney (parathyroid adenoma) Function improved on Some residual function Left hydronephrosis Non-functioning left of IVP after conduit due to prostatic left kidney kidney carcinoma Non-functioning left kidney Non-functioning right kidney

Result of 1Z1IH series

Some residual function Tuberculous involve- Tuberculous of left kidney ment requiring surgery pyelonephritis

Non-functioning right Hydronephrotic right Hydronephrotic kidney kidney atrophy Function improved after left ureterotomy. BUN-168 > 10 mg. per 100 ml.

Bilateral non-function Some function remains Obstructed ureters due to metastases from bilaterally; better function on left side breast

8

Non-functioning left kidney

Non-functioning left kidney

Left ureteropelvic obstruction

10*

Radiopaque left staghorn calculus

Functioning left kidney with partial

Left staghorn calculus Nephrolithiasis and not removable chronic pyelonephritis

11

Non-functioning left

12

obstruction Some function of left

Chronic pyelonephritis and hydronephrotic

atrophy

Obstruction due to

carcinoma of bladder kidney kidney of right Right ureteral calculus Non-functioning right Some function kidney at six minutes kidney

function Improved after ideal conduit function Improved after ureterolithotomy

Five show non-function on IVP and 131IH series. Severity of renal lesions confirmed histologically. Five show non-function on IVP, but function on 131IH series. Function improved after surgery or irradiation. *Two show non-function on IVP, but function on 131IH series. Kidneys required removal despite residual function.

least one ureter was patent. A typ¬ ical example was a patient who had chronic glomerulonephritis with a BUN of 225 mg., serum creatinine of 15.7 mg. and creati¬ nine clearance of 3.4 ml./minute.

relatively less affected. In time, the contrast material builds up sufBslow filtration, water reThis category comprised 92 pa¬ ciently byand reduced urine flow to tients, the majority of whom sorption be seen radiographically by dif¬ suffered from calculi (23 cases), absorption. Radiopaque ureteropelvic obstruction (23 cases) ferential in material a dilated pelvis is dilut¬ or ureteral obstruction (16 cases). it less visible on the When there is no azotemia the ed, making whereas dilution of a 131IH series usually does not have radiograph, in a dilated radiopharmaceutical an advantage over the IVP in es¬ diminish its visuali¬ not does pelvis tablishing the diagnosis of obstruc¬ zation. tion, but it is more sensitive in The 131IH series may show an demonstrating alterations in func¬ initial prominent defect at the tion and can detect the nature of hilum of the kidney due to the the abnormality in a shorter time. dilated system and a pelvicalyceal A possible explanation for this is within of gradual activity build-up that in obstructive uropathy the in time. the defect within the tubules pressure rapidly In three cases of obstructive rises and exceeds glomerular filtra¬ tion pressure. This impairs the fil¬ uropathy the obstruction and resid¬ tration of contrast material from ual function were shown earlier the blood to the kidney, while the than with the double-dose IVP. The of contrast material Obstructive lesions without

azotemia

Renal failure due to obstruction Thirteen cases had a marked azotemia secondary to urinary obstruc¬ tion. Carcinoma of the urinary bladder and prostrate were the most common cause, but extrinsic compression due to lymphadeno¬ pathy, neoplasm and retroperitoneal fibrosis were also found. In these cases there was delayed appearance of activity in the kid¬ neys and a prolonged transit time, but eventually the activity accum¬ ulated in a dilated upper collecting system, which is the hallmark of the diagnosis (Fig. 3). tubular concentration of 131IH is 1268 C.M.A. JOURNAL/DECEMBER 5, 1970/VOL. 103

presence

kidney of one appreciated until patient after four hours (Fig. 4a), whereas the organ was clearly seen in the 0-3 minute scintiphoto of the 131IH series (Fig. 4b). In another case 131IH function was exhibited at 15 minutes, but a radiographic nephrogram emerged only after 24 in the obstructed was

not

series uncovered unilateral renal and creatinine 2.2 mg. (Figs. 5a disease in one hypertensive when and 5b). the IVP showed normal function. A patient with long-standing left Miscellaneous renal artery occlusion and collat¬ One patient had pyelitis of preg¬ eral circulation developed suspect- nancy and partial ureteral obstruc¬ ed emboli with renal infarction. tion. This was well shown with The IVP exhibited overall poor 100 fxc. of 131IH as an unusually function within the kidney, but the prolonged drainage impairment 131IH series revealed focal areas of relative to the normal urinary runconcentration. In focal renal ische¬ off features of the physiological mia the dependent calyces may fill dilatation of pregnancy. The ab¬ by diffusion with contrast material sorbed radiation dose is less than excreted by the functioning por¬ from serial roentgenograms of an tions of the kidney, thus rendering IVP. More information is necessary the calyceal pattern spuriously nor¬ about normal drainage in preg¬ mal. On the other hand, early nancy to differentiate minor super¬ scintiphotos of the 131IH series will imposed obstructions. reveal the infarct, as the radioNo additional information was pharmaceutical is not concentrated gleaned from the two cases of in the dependent tubules. hematoma studied.

hours. The extent of remaining renal function is important for urological management in chronic obstruc¬ tion. Persistence of slight function might result in considerableofrenal improvement with removal the obstruction, if a refractory infec¬ tion is not a complicating factor. In our experience an absence of 131IH concentration indicates that the organ is not salvageable. Twelve cases of obstructive uro¬ 131IH series compared with IVP pathy showed no function by IVP Inflammatory lesions (Table II), but in seven of these A total of 11 patients were includ¬ as a test of renal function the 131IH series depicted residual ed in this category, four of whom In 42 cases it was considered in function. Five improved with sur¬ had that the 131IH series was proved pyelone¬ review gical repair or irradiation therapy, phritis. Again,tuberculous more sensitive to renal function the 131IH was series whereas the other two required more sensitive than the IVP in re- than the IVP. This is due nephrectomy, in one instance vealing residual function, but the partly to the fact thatprobably instrumentabecause of extensive tuberculous decision to the presence of perform an operation tion for detecting involvement, and in the other case was based mainly is more sensitive, on the refrac¬ radioactivity the presence of a large staghorn toriness of the condition to medical albeit of poorer resolution, than calculus that could not be re¬ the radiographic method of estimoved without sacrificing the or¬ management. the concentration of radio¬ mating gan. Five out of 12 cases had no material. There are other paque lesions 131IH visualization, and at opera¬ Space-occupying tion severe atrophy, inflammation A number of cysts and one abscess were encountered incidentally in or necrosis was present. In bilateral obstruction the 131IH the investigation of azotemia. In series is a quick and easy method two confirmed cases the lesion was of determining which kidney has apparent on the 131IH series, but better function if a urinary diver- not seen on the IVP because the calyces were not displaced. One sion is considered. 3-cm. carcinoma of the kidney was missed both by excretory uroVascular lesions graphy and the 131IH series. The There were 16 cases in this cate¬ patient had severe renal failure and gory. These included renal artery the statistics of counting were too occlusion, bilateral and unilateral poor to permit resolution of the small vessel disease, emboli and in¬ lesion. Another lesion, a reticulofarction. In general the 131IH plasmacytoid granuloma in a pa¬ series did not add appreciably to tient with renal failure, was ob¬ the information derived from the served by IVP and retrograde IVP. In severe vascular lesions as¬ pyelography, but the 131IH series sociated with marked loss of func¬ failed to show it. tion the 131IH series demonstrated viability earlier and more clearly Unilateral non-functioning kidney PIG. 4a.A case of left obstructive uro¬ than the IVP. etiology unknown pathy without azotemia. Excretory uroat four shows the develop¬ gram 131IH renography is used in sus- Three cases constituted this group. ing- nephrogramhours on the left side. pected cases of renovascular hyper¬ In one the functioning kidney was right FIG. 4b.131IH series shows a normal which has drained by two tension as the transit times are reported as normal on the IVP, but hours. kidney The obstructed left kidney is vis¬ ualized with 203Hg-chlormerodrin (Frame more quantitative than the "eye- the 131IH series indicated an im¬ 1), and as early as three minutes with !3iIH (Frame 2). At two hours there is baU" estimation of serial three- to pairment which was verified by an accumulation of the test ag-ent in a five-minute scintiphotos. The 131IH abnormal chemistry: BUN 48 mg. dilated pelvis (Frame 6). C.M.A. JOURNAL/DECEMBER 5, 1970/VOL. 103 1269

technical factors. In slim patients lower kilovoltage radiographs are possible, and this enhances the visualization of the radiopaque material. Obese patients require a higher kilovoltage with consequent penetration of the radiopaque material and poorer visualization. Overlying bowel contents and as¬ cites further depreciate the roent¬ genogram. 131IH has a principal gamma emission of 364 kev which is essentially impervious to the above factors, and the count rate is proportional to the amount of activity in the kidneys. This permits the estimation of renal func¬ tion on the basis of time of appear¬ ance, transit time and rate of

drainage. There. were 14 cases in which subtle renal impairment was missed by the IVP and detected

with the 131IH series. In an addi¬ tional 22 cases, where the IVPestimated function wasnil or very poor, the radionuclide study gave a clearer indication of the amount of function remaining, and whether or not it was obstructed, in spite of the azotemia that was /present.

at 24

information within an hour. Three cases of chronic obstruc¬ tion and renal impairment showed a

involved side. This was due to an accumulation and retention of radioactivity in the dilated pelvi¬ calyceal system. The early 131IH scintiphoto revealed a delayed ap¬ pearance of the test agent on the diseased side followed by retention

positional

subject

to

probe

A concomitant 131IH renogram and series is more desirable than either one alone to assess the amount of radiopharma¬ ceutical present and its distribu¬ tion. This is possible with the Pho/ Gamma split crystal mechanism or ancillary data processing devices. In prolonged transit times it is not practical to keep the patient imerrors.

subsequent pictures. performance of 203Hg-chlormerodrin in demon¬ strating slightly decreased or mini¬ mal residual function, the higher in

The radiochlormerodrin scintithe functioning photo (Frame 1) exhibits function on the left. right kidney with no normal than uptake in A slightly higher the liver is recorded. A isiih series the demonstrates (Frames 2. 3 and 4) kidney, but single functioning- righttransit as time there is also a prolonged considerable parenchymal retention is ob¬ is This served at 30 minutes (Frame 4).

FIG. 5a

more

and

consonant with a BUN of 48 mg. creatinine of 2.2 mg. per 100

serum

ml. than the IVP findings.

In view of the poor

absorbed radiation dose, and the three erroneous results cited above, it is not recommended as a test agent, save for the detection of space-occupying disease in the absence of azotemia. 131IH series

laboratory Blood

FIG. 5b.A 10-minute IVP film showing non-functioning on the left and an ostensibly normal right kidney.

mobilized for

renography, whereas

periodic imaging

is not

a source

of discomfort.

131IH series compared with radiochlormerodrin renal

scintiphotography With

progressive renal failure the

131IH series was clearly a much better indicator of renal morphology than 203Hg-chlormerodrin. Also, the liver has a greater avidity

for clearing 203Hg-chlormerodrin than 13lIH, and this tends to obscure the right kidney (Fig. 5a). In some cases improved visualiza¬ tion of the organs could be ob¬ tained with 203Hg-chlormerodrin

1270 C.M.A. JOURNAL/DECEMBER 5, 1970/VOL. 103

compared with

data

nitrogen As antici¬ the more severe the azo¬ temia, the poorer the function demonstrated on the 131IH series. The relationship is not direct, how¬ ever, and probably depends on a multitude of factors. Often in two similar cases with similar BUN's, one would show some residual function and the other would show none. In the presence of a rising BUN, worse function was demon¬ strated, as might be expected. In one case of Alport's syndrome (hereditary nephritis and deafness) very poor renal function was seen despite a BUN of 78 mg. per 100 ml., while another patient with glomerulonephritis had bilateral visualization with a BUN of 164 mg. Serum creatinine and creatinine clearance.The secretion of crea¬ tinine in the tubules follows a simi¬ lar mechanism to the secretion of para-amino hippuric acid.8 It would be anticipated that the ap¬ pearance and disappearance of 131IH in the kidney would parallel the creatinine clearance. This as¬ sumption was generally true. The measurement of creatinine clear¬ ance requires complete collection of the 24-hour urine volume. Re¬ grettably, this is not always properly performed, and often creatinine clearances calculated

pated,

function

gram, it is not

paradoxically higher concentra¬ 203Hg-chlormerodrin on the

tion of

131IH series compared with the renogram as a test of renal

A review of 20 different parameters of renogram evaluation disclosed that, in general, the greatest diag¬ nostic accuracy was obtained for parameters concerned with the drainage phase of the renogram.5 However, since the renogram probes detect only the presence of activity and not its location, the retained radiopharmaceutical in a dilated renal pelvis, obstructed calyx, spastic ureter, or within the parenchyma may produce abnor¬ mal drainage patterns in all these situations. On the other hand, the 131IH series depicts the distribution of activity, and can differentiate retention in the renal pelvis and in the parenchyma. Unlike the reno¬

hours, but the 131IH gave the

same

urea

with an incomplete collection give causes. The risks of cytoscopic falsely low clearance rates. In three instrumentation and high-dose IVP cases the patients with at least one may thus be avoided. The amount completely normal kidney as of iodine in the '311H doses used is demonstrated by '311H series, BUN, less than in the daily ingestion of and serum creatinine levels iodized table salt. showed pathologically low creatitechnique is a more sensinine clearance rates. These were tiveThe indicator of the nature of renal apparent artifacts due to incom- impairment than radiochloromeroplete collection. In five cases, how- drin renal imaging. '311H renoever, 1311H series demonstrated ab- graphy is relatively non-specffic normal renal function despite nor- when an abnormal curve is obmal BUN, and normal or only tained, whereas the 1311H series slightly elevated serum creatinine differentiates between obstructive levels. These five cases also had ab- and non-obstructive abnormalities normal creatinine clearances. Every because the distribution of activity case of bilateral poor function is visualized. It is also possible to demonstrated by 1311H series also follow the clearance of 1311H for had abnormal creatinine clear- long periods (up to several days if ance. need be) while this is impractical With this evidence, we believe with the renogram. that the hippurate excretion paralSpace-occupying lesions can be lels the creatinine clearance more demonstrated in the early phase, closely than the BUN. The 1311H but changing the distribution of series has an advantage over the activity does not permit creatinine clearance in that the in- imaging using oblique repeated dividual kidney functions can be views. For this reason or other 1311H is not compared. recommended to replace radiochlormerodrin in the detection of Conclusions renal masses unless renal function Serial 1311H renal scintiphoto- is so reduced that imaging with graphy is a safe and simple method radiochlormerodrin cannot be acof estimating renal function, cor- complished. '311H series is prerelating best with creatinine clear- ferred to radiochlormerodrin when ance determinations, but having renal masses are not a considerathe added value of providing a tion. In obstructive uropathy the comparison of the function of each radiochlormerodrin scan may give kidney. It is more sensitive than a false indication of good function. the IVP in demonstrating subtle This is a useful procedure in loss of renal function in marginally long-term patient follow-up, when abnormal kidneys, and is better changing function rather than able to demonstrate minimal resid- morphology is being evaluated. It ual function in severely diseased will decrease the frequency of' IVP kidneys. It is of significant pre- examinations and will lower patient dictive value in obstructive uro- exposure to radiation and contrast pathy when a decision to repair or material. remove a kidney must be made. It As in other radionuclide imaging will localize the side of better function if nephrostomy or urinary procedures, the resolution of anatomical details is poor. The 1311H diversion must be performed. is not intended to replace Localized areas of abnormal series conventional techfunction, as in focal inflammation niques in the radiographic diagnosis of renal and renal infarction,. are easily lesions or in demonstration of demonstrated. In the IVP the col- morphologicalthefeatures. In cases lecting system of a. non-functioning where renal function is poor segment may be passively filled by the IVP is of little value, orandis contrast excreted by the remainder contraindicated for other reasons, of the kidney, thus obscuring the the 1311H series may contribute diagnosis. morphological details. In general, Serial 1311H renal scintiphoto- the two procedures are complegraphy is valuable in renal failure mentary, rather than competitive, to differentiate obstructive uro- and should be viewed in conjuncpathy from renal and prerenal tion.

R.sum. La scintiphotographie re'nale en s.rie avec le radiohippurate Les auteurs analysent les r6sultats des scintiphotographies r.nales pratiqu6es en s&ie avec le radiohippurate" chez 222 malades. us comparent les r6sultats de cette m6thode avec ceux qu'on obtient de l'urographie intraveineuse, du dosage de l'azote ur.ique, de la cr6atinine s&ique et de la clearance de la cr.atinine. References 1. BURKE, G. AND HALKO, A.: J. A. M. A.,

197: 15, 1966. 2. Idem: Radiology, 88: 704, 1967. 3. DORE, B. K., TAPLIN, G. V. AND JOHNSON, D. E.: J. A. M. A., 185: 725, 1963. 4. LUBIN, B., LEVITUS, Z. AND SHIMEONI, A: J. Nuci. Med., 9: 567. 1968.

5. MEADE, R. C., HORGAN, J. D. AND MADDEN, J. A.: Ibid., 10: 40. 1969. 6. NORDYKE, H. A., Turns. M. AND

BLAHD, W. H.: J. Lab. Clin. Med., 56: 438. 1960.

7. PITTs, H. F.: Physiology of the kidney and body fluids, 2nd ed., Year Book Medical Publishers Inc., Chi-

cago, 1968, p. 134. Idem: Ibid., p. 135. ROSENTHALL, L.: Radiology, 87: 298, 1966. TAPLIN, G. V. et al.: J. Lab. Cli. Med., 48: 886. 1956. 11. Turns, M.. PosNIcIC, B. AND NORDYKE, B,. A.: Proc. Soc. Rxp. Riol. Med., 103: 497. 1960. 12. WINTER, C. C.: J. Urol., 76: 182. 1956. 8. 9. 10.

13. Idern: Radioisotope renography, The Williams & Wilkins Company, Baltimore, 1963.

(Continued from page 1265) Resum6 Le traitement de l'angine de poitrine rebelle par implantation d'un stimulateur du nerf du sinus carotidien. Le pr6sent article expose les grandes lignes du traitement de 1'angine de poitrine rebelle et donne les r6sultats d'une premiere ann6e d'utilisation d'un stimulateur du nerf du sinus carotidien. Get appareil a 6t6 install6 chez sept malades. Chez tous, existaient des preuves objectives d'une action stimulatrice, manifest.e par une chute de la tension art6rielle et du pouls, ou de l'un de ces deux parametres. Chez tous les malades, l'am6lioration consid6rable leur a permis de mener une vie plus agr& abl&. Chez un malade, l'am6lioration avait 6t. faible au d6but, mais on a d6couvert qu'il s'agissait d'une panne m6canique de l'appareil, panne qui a pu .tre corrig6e. Malheureusement, ce malade est d6c6d6 d'un infarctus aigu du myocarde, 15 mois apr.s l'op6ration.

C.M.A. JOURNAL/DECEMBER 5, 1970/VOL. 103 1271