Glomerular filtration rate estimation using Tc-99m DTPA

renal scintigraphy in renal transplant recipients:

comparison between Gates' method and multiple linear
regression modeling of scintigraphic factors

Daris Theerakulpisut1, Bandit Thinkhamrop2, Sirirat Reungjui1

1
Faculty of Medicine, Khon Kaen University
2
Faculty of Public Health, Khon Kaen University

Abstract

Background: Multiple methods for estimation of glomerular filtration rate (GFR) in renal
transplant recipients are available. Blood and urine sampling methods are considered as the
gold standard but are invasive and time-consuming. Measurement of 24-hour urine creatinine
clearance (CrCl) is an acceptable alternative but is still a cumbersome procedure. Renal
scintigraphy (RS) with Tc-99m DTPA has long been used for evaluation of renal graft
perfusion and function. The estimated GFR (eGFR) obtained from RS in renal transplant
recipients is adapted from Gates' study in 1972 which was originally done in native kidneys
by simple linear regression using CrCl as the reference, therefore the method may not be
applicable for use in newer gamma cameras in the present day.

Objectives: To construct a regression model of factors obtained from Tc-99m DTPA RS to

estimate glomerular filtration rate in renal transplant recipients and to compare the precision
of the new model to that of the traditional Gates' method.

Methods: Factors obtained from Tc-99m DTPA RS including renal uptake, background
activity, kidney depth, time-to-peak activity, area under renogram curve, area under
background activity curve was modeled against 24-hour urine creatinine clearance using
stepwise multiple linear regression. Once the most robust model was determined, the
resulting equation was used on the same dataset to determine the eGFR. With the 24-hour
CrCl as the reference, Bland-Altman plots were used to define the limits of agreement of the
eGFR from the new equation and Gates' method. Scintigraphy was considered to be in
agreement with CrCl if 95% CI of limits of agreement did not exceed the maximum allowed
difference of 10 mL/min. Fisher z-transformation was used to determine the confidence
interval of the correlation coefficients between the eGFR from the new equation and Gates'
method.

Results: From June 2013 - December 2016, 240 patients were included. The mean 24-hour
CrCl was xx.x xx.x mL/min. Factors from Tc-99m DTPA RS that made up the most robust
model were renal uptake, background activity, kidney depth, and time-to-peak activity
(adjusted R2 0.9xxx, p = 0.00x). The eGFR from the new equation correlated better with 24-
hour CrCl than that obtained from Gates' method with correlation coefficients of 0.9xxx
(95%CI 0.xxx - 0.xxx) vs. 0.8xxx (95%CI 0.xxx - 0.xxx), p = 0.00xx. Bland-Altman plots
revealed mean difference between eGFR of the new method and 24- hour CrCl of x.x
mL/min (95% CI limits of agreement -xx.x to xx.x) while eGFR from Gates' method had
corresponding values of x.x mL/min (95% CI limits of agreement -xx.x to xx.x).

Conclusion: The constructed multiple linear regression model of Tc-99m DTPA renal
scintigraphic factors provides more precise estimation of glomerular filtration rate and was in
greater agreement with 24-hour CrCl when compared with the traditional Gates' method.
Factors that make up the most robust model include renal uptake, background activity, kidney
depth, and time-to-peak activity.

Keywords: Renal transplantation, renal scintigraphy, radionuclide imaging, glomerular

filtration rate