Captopril Renography

Radionuclide renography without ACE inhibition has limited use for the
functional or anatomic diagnosis of renovascular disease.

Physiologic principle -- Loss of preferential vasoconstriction of the efferent

arteriole that is mediated by AII which maintains the glomerular pressure
gradient in cases of RAS.

This loss of postglomerular pressure results in a decreased GFR of the kidney

distal to the stenosis, which is measured noninvasively by radionuclide
renography.

TECHNIQUE:

The study is performed in well-hydrated patients on liberal salt intake.

ACE inhibitors are discontinued for 3 to 5 days before the study, but other
antihypertensives may be continued

Oral hydration is continued on the day of the procedure.

Oral captopril (25 to 50 mg) is usually used, although IV enalapril

(0.04 mg/kg) can be used as well

The captopril renogram is obtained 1 hour after the captopril dose.

The use of furosemide has also been suggested to improve the accuracy of ACE
renography

Optimal radionuclide agents:

The most commonly used agents are

 Technetium 99m (99mTc)–diethylenetriaminepentaacetic acid (DTPA)
 Iodine 131 (131I)–orthoiodohippurate (OIH)
 99mTc-mercaptoacetyltriglycine (MAG3).

The imaging characteristics of 99mTc compounds are better than that of

131I compounds.

On the other hand, OIH and MAG3 are excreted by both glomerular filtration and
tubular secretion, whereas DTPA is excreted by glomerular filtration only,
making it less optimal for patients with renal dysfunction.

To date, 99mTc-MAG3 has shown the best results for captopril renography,
especially in patients with impaired renal function

INTERPRETATION

Captopril renographic diagnostic criteria have not been well standardized.

Criteria suggested by the Consensus Panel on Captopril Renography

Two categories of information are used:

Asymmetry of renal size and function as suggested by the scintigraphic

images

Specific captopril-induced changes in the renogram.

 Delayed time to maximal activity (>11 minutes),

 Significant asymmetry of peak activity of each kidney
 Marked cortical retention of radionuclide
 Marked decrease in the GFR of the ipsilateral kidney.

For radionuclides with tubular excretion (131I-OIH and 99mTc-MAG3), the ratio
of 20-minute counts to peak counts can also be used.

Normally less than 0.3, a 0.15 change is considered significant.

A small poorly functioning (30%) kidney that shows no change after ACE
inhibition, as well as bilateral symmetrical change after ACE inhibition,
is considered to be moderately indicative of RVH

Sensitivity - Approximately 90% to 93%

Specificity - Approximately 93% to 98%
Captopril renography is predictive of a cure or improvement in blood
pressure after revascularization in 80% to 90% of cases

 The presence of bilateral renal artery stenosis,

 Renal artery stenosis to a solitary kidney, or
 Impaired renal function (serum creatinine level > 2.5 to 3 mg/dL)
decreases the accuracy of captopril renography.