International Journal of Clinical Medicine, 2013, 4, 543-547
Published Online December 2013 (
Open Access IJCM
Short Term Prognostic Utility of Tc-99m DMSA Renal
Imaging in Sepsis Induced Acute Renal Failure;
Provisional Data
Amr Amin1, Hatem Nasr1, Gehan Younis1, Hatem Gamal2
1Nuclear Medicine Unit, Faculty of Medicine, Cairo University , Cairo, Egypt; 2Intensive Care Unit, Faculty of Medicine, Cairo Uni-
versity, Cairo, Egypt.
Received October 8th, 2013; revised November 3rd, 2013; accepted December 2nd, 2013
Copyright © 2013 Amr Amin et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Sound prognostic data in sepsis induced acute renal failure (SARF) are lacking especially on the short
term outcome [STO] in the intensive care unit [ICU]. We addressed the use of Tc-99m DMSA [2,3-dimercaptosuc-
cinicacid] renal cortical imaging as a prognostic tool in SARF. Methods: Forty patients with acute renal failure due to
sepsis [age range 15 - 74 years; median 44.5] were subjected for full history taking complete physical examination, rou-
tine ICU monitoring, routine laboratory investigations, APACHE II [Acute Physiolog y and Chronic Health Evaluation]
and SOFA [Sequential Organ Failure Assessment] together with Tc-99m DMSA cortical renal scintigraphy. Patients’
death in the ICU or discharge was considered as the end point of the study representing the so-called short term out-
come [STO]. Results: 25% mortality rate [10/40] was found along the admission period in the ICU. All non-survivors
were abnormal with DMSA imaging [NPV & PPV 100% & 66.7% respectively]. Abnormal DMSA cases showed sig-
nificant positive associations with serum creatinine at admission [r = 0.5 ; P 0.02]; admission duration [r = 0.4; P 0.002];
APACHE II score [r = 0.5; P 0.004] and STO [r = 0.4; P 0.03]. Statistically significant difference was elicited between
subjects with normal and abnormal DMSA regarding the same parameters. Conclusion: This preliminary data could
raise Tc-99m DMSA renal imaging as a prognostic tool in SARF that could allow influential interference to prohibit
dramatic outcomes as mortality.
Keywords: Acute Renal Failure; Tc-99m DMSA; Sep sis Induced Acute R e n a l Failure
1. Introduction
Acute renal failure [ARF] is a sudden sustained decline
in glomerular filtration rate [GFR] usually associated
with uremia and a fall in urine output with a high
mortality rate [1]. Factors affecting its incidence and
outcomes are unclear therefore making optimal decision
for patients’ care is hindered [2]. Tc-99m labeled DMSA
(2,3-dimercaptosuccinicacid) is avidly taken up by cells
of the proximal tubule, with about 35% of the injected
activity being localized in the renal cortex by one hour
[3]. The renal uptake of Tc-99m DMSA parallels the
renal function as determined b y GFR and accordingly its
uptake is significantly decreased in nephropathy [4,5]
which is accepted as a poor prognostic sign [6]. Bern-
heim et al. in 1976 proposed renal scintigraphic scanning
as a tool to assess the prognosis of ARF using hippuran
and concluded that its uptake was a parameter which
authorized the prognosis of a favorable course whereas
its absence permitted one to envisage an unfavorable
course [7]. However, in a case report published in 1986;
a 35-year-old patient developed ARF on top of acute tu-
bular necrosis requiring hemodialysis and they stated that
failure to visualize acutely injured kidneys with Tc-99m
DMSA did not preclude recoverable function [4], while
the reverse was elicited in another two studies using hip-
puran [8,9]. Besides, much research is still needed be-
cause our understanding of what happens to the kidney in
ARF is still poor [10]. Hence, we aimed to evaluate the
predictive role of Tc-99m DMSA cortical scanning in
predicting the short term outcome [STO] of the ad-
mission period in the intensive care in sepsis-induced
ARF patie n ts [SARF] .
Short Term Prognostic Utility of Tc-99m DMSA Renal Imaging in Sepsis
Induced Acute Renal Failure; Provisional Data
2. Patients and Methods
Forty patients with SARF were enrolled in the study and
monitored for their ICU prognosis and outcome. ARF
patients with previous renal transplantation, known urin-
ary tract abnormalities or surgery or those with pre-exist-
ing CKD requiring regular haemodialysis and advanced
congestive heart failure were excluded. Patients were
subjected for routine ICU monitoring, routine lab s, Elec-
trocardiography, APACHE II [Acute Physiology and
Chronic Health Evaluation] and SOFA scores [Sequen-
tial Organ Failure Assessment]. APACHE II is used as
an indicator of severity of illness and likelihood of sur-
vival [10]. The patients were allocated to Tc-99m DMSA
cortical renal scintigraphy as performed in accordance
with a standard protocol. Imaging was done 3 hours after
injection of the trace 111 MBq [3 mCi] with obtained
anterior and poster ior views su ing “PHILIPS AX IS-2 VT;
the Netherlands” gamma camera. The scintigraph ic study
findings were blindly interpreted and defined as normal
or abnormal. We classified abnormal DMSA scans as
based on visual assessment of images into GRADE 1
[Gr1; mild to moderate reduction in overall uptake with
mild to moderate elevation of background] and GRADE
2 [Gr2; severe reduction in overall uptake with severe
elevation of background]. Patients’ death in the ICU or
discharge was considered as STO that was used in
calculating positive and negative predictive values [PPV
and NPV].
3. Statistical Analysis
Descriptive statistics included frequencies and percent-
ages for each variable while numerical measures were
represented as mean ± SD. Cross tabulation was utilized
to describe the relations between variables using the
contingency coefficient. T-test for testing the differences
between samples was used. Correlations were done using
Pearsons and Spearman correlation coefficients. Also;
NPV and PPV were calculated and P value <0.05 was
considered significant.
4. Results
40 patients [22 female & 18 males; mean age 47.2 ± 17
years] with ARF due to sepsis were enrolled in th is study.
Regarding their medical history; 32.5% were smokers
and hypertensive (using B-blockers and Angiotensin con-
verting enzyme inhibitors [ACE-I]), while diabetes was
found in 17.5% [using oral hypoglycemic drugs]. Sepsis
was the inducing factor for ARF with bronchopn eumonia
and pyelonephritis as the dominating clinical sources
[27.5% and 22.5% respectively]. Other less sources in-
cluded peritonitis and post-surgical sepsis [7 for each;
17.5%] and finally infected pace-maker [3 patients;
7.5%]. According to the STO in the ICU; patients were
classified into survivors and non-surv ivors [Figures 1(a)
and (b)] representing 30/40 [75%] and 10 [25%] respec-
tively. Their characteristics are detailed in Table 1.
According to the STO; patients were classified into
survivors and non-survivors representing 30/40 [75%]
and 10 [25%] respectively. DMSA cortical imaging
showed 25 and 15 cases as normal and abnormal [5 Gr1
and 10 Gr2 cases] respectively and all the non-survivors
were Gr2. Correlations between DMSA cortical imaging
and patients’ STO [survivors and non-survivors] with
various patients’ factors are shown in Table 2. There w a s
statistically significant difference between subjects with
normal and abnormal DMSA regarding need of mecha-
nical ventilation, serum creatinine on admission, admis-
sion duration, APACHE II Score and STO [P 0.02, P
0.03, P 0.01, P 0.01 and P 0.03 respectively]. Abnormal
DMSA showed significant positive associations only
with serum creatinine at admission time [r = 0.5; P 0.02],
admission duration [r = 0.4; P 0.002]; APACHE II score
[r = 0.5; P 0.004] and STO [r = 0.4; P 0.03]. Calculated
Figure 1. Tc-99m DMSA cortical renal scan [Left: anterior
and right: posterior]. (a) Non-survivor case where G2 was
elicited and the patient died a week after admission to ICU
nd (b) Survivor images with normal cortical uptake. a
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Short Term Prognostic Utility of Tc-99m DMSA Renal Imaging in Sepsis
Induced Acute Renal Failure; Provisional Data
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Table 1. Clinical and investigatory characteristics of the studied patients.
Survivors [n. 30] Non-survivors [n. 10]
Age [Mean ± SD] 47.4 ± 16.0 46.6 ± 20.3
Gender [n. %]
Male [n. 18]
Female [n. 22]
13 [72.2%]
17 [77.3%]
5 [27.8%]
5 [22.7%]
ICU admission duration [Days] 12.9 ± 7.7 19.1 ± 13.7
Creatinine [mg/dl]
At admission
At discharge
4.4 ± 1.6
2.2 ± 1.7
3.6 ± 0.9
2.9 ± 1.4
APACHE II score 19.6 ± 4.2 23.9 ± 3.2
SOFA score 7.1 ± 1.6 8.3 ± 1.7
Abnormal renal sonography 8/30 [26.5%] 3/10 [30%]
Echocardiographic findings
Normal [n. 40]
Abnormal [n. 0]
30 [75%]
10 [25%]
Need for mechanical ventilation 7/30 [23.3%] 9/10 [90%]
Need for dialysis 4/30 [13.3%] 1/10 [10%]
DMSA scan
Normal [n. 15]
Abnormal [n. 25]
15/15 [100%]
15/25 [60%]
0/15 [0%]
10/25 [40%]
Table 2. Correlations betw ee n DMSA c o r t ical imaging and patients’ short term final outcome with various patients’ factors.
DMSA scan Short term final outcome
Patients’ parameters Normal [n. 15] Abnormal
[n. 25] r-value
P value Survivors
[n. 30] Non-survivors
[n. 10] r value
P value
Age 43.3 ± 21 40.5 ± 19 r = 0.1
P 0.7 47.4 ± 16 46.6 ± 20.3 r = 0.1
P 0.8
6 [40% ]
9 [ 60%]
12 [48%]
9 [52%]
r = 0.2
P 0.5
13 [43.3%]
17 [56.7%]
5 [50%]
5 [50%]
r = 0.1
P 0.7
Smoking 5 [33.3%] 8 [32%] r = 0.1
P 0.9 9 [ 30%] 4 [ 40%] r = 0.2
P 0.6
Source of sepsis
- r = 0.2
P 0.3
- r = 0.2
P 0.1
Need of hemodialysis 0 5 [20%]
r = 0.2
P 0.07 4 [13.3%] 1 [10%] r = 0.2
P 0.7
Need of mechanical
ventilation 5
[33.3%] 11
[44%] r = 0.5
P 0.02 7/30 [23.3%] 9/10 [90%] r = 0.5
P 0.0001*
Serum creatinine
On admission
On Discharge
3.8 ± 1
2.2 ± 1.7
5.5 ± 2
2.9 ± 1.5
r = 0.5
P 0.02*
r = 0.2
P 0.9
4.4 ± 1.6
2.2 ± 1.7
3.6 ± 0.9
2.9 ± 1.4
r = 0.2 P 0.1
r = 0.1 P 0.2
Abnormal renal
sonography [n. 11] 0 11 [44%]
r = 0.3
P 0.06 7/30 [23.3%] 2/10 [ 2 0%] r = 0.1 P 0.8
Admission duration 10.65 ± 7.8 18.1 ± 14.2 r = 0.4
P 0.002 12.9 ± 7.7 19.1 ± 13.7 r = 0.3
P 0.08
APACHE II score 16.2 ± 6 22.4 ± 8.1 r = 0.5
P 0.004* 17.6 ± 4.2 23.9 ± 3.2 r = 0.5
P 0.001*
SOFA score 5.5 ± 2 8. 5 ± 3 r = 0.3
P 0.051 7.1 ± 1.6 8.3 ± 1.7 r = 0. 3
P 0.052
Short term final outcome
15/15 [100%]
0/15 [0%]
15/25 [60%]
10/25 [40%]
r = 0.4
P 0.03*
*P < 0.05 is considered si
Short Term Prognostic Utility of Tc-99m DMSA Renal Imaging in Sepsis
Induced Acute Renal Failure; Provisional Data
PPV and NPV for DMSA imaging were 66.7% and 100%
5. Discussion
This study was carried out on 40 SARF patients and
showed a mortality rate of 25% along the ICU admission
period. Abnormal Tc-99m DMSA revealed a significant
positive asso ciation with STO [r = 0.4; P 0.03]. Although
different modalities for this clinically relevant task has
been proposed, to our knowledge no previous studies
have reported using Tc-99m DMSA cortical imaging as a
prognostic tool; hence, this prospective study was ad-
Our patients were recruited from ICU unit, as in Egypt
ARF is usually treated in ICU and attributed mostly to
sepsis. The latter was reported as the commonest cau-
sative factor of ARF (up to 50%) [2,10,11]. In fact, ARF
is nowadays mostly observed as part of the multi-organ
dysfunction syndrome in severe sepsis and septic shock
[12]. 10/40 [25%] of our patients died in the ICU ad-
mission period and this agrees with Prescott et al. study
as many of his deaths [20% - 30%] were very early
where ARF was sepsis-induced. They concluded that the
presence of sepsis increased the risk of death; both as an
etiological factor and poor indicator of prognosis in a
startling manner [2].
Also, we have chosen the German Prevalence Study
[GPS] [13] for comparison with our elicited data as they
studied a cohort of ARF patients with and without sepsis
and compared both groups regarding patients’ various
factors and reported significant differences between
serum creatinine at admission, APACHE II and SOFA
scores. They reported a higher mortality rate [64.4% vs.
25%]. This disagreement could be explained by our small
patients’ number and the relatively younger age of our
cases that carries in general an expected better outcome.
Also, pulmonary infection was the most frequent source
for sepsis as in our study [59% vs. 40%]. In our study
significant statistical associations were found between
DMSA and STO, serum creatinine at admission, APACHE
II and need for mechanical ventilation in concordance
with the same significant parameters of GPS.
We tried to find an explanation for our findings; as
DMSA is avidly taken up by cells of the proximal tubule
and with sepsis damage of the proximal tubules might
occur and [3], so the higher the damage the lower is
DMSA uptake and the worst is outcome. Hence in Gr2
pattern extensive damage of the proximal tubules was
found in non-survivors.
Finally, since kidney injury in SARF plays an im-
portant role in prognosis; this preliminary data could
raise Tc-99m DMSA cortical imaging as a tool to predict
STO in such patients with 100% and 66.7% NPV and
PPV respectively. As said by Niccolo Machiavelli [The
Prince, 1513], “It ought to be remembered that there is
nothing more difficult to take in hand, more perilous to
conduct or more uncertain in its success than to take the
lead in the introduction of a new order of things” hence,
we tried to introduce DMSA renal imaging as a pro-
mising prognostic radiopharmaceutical with subsequent
interference to ban serious sequences as mortality. How-
ever, we recommend further larger studies to support
these provisional data.
6. Conclusion
Tc-99m DMSA cortical imaging could be raised as a
diagnostic tool to predict short term outcome in such
sepsis induced acute renal failure patients with 100%
NPV and 66.7% PPV respectively that could allow in-
fluential interference to prohibit dramatic outcomes as
7. Acknowledgements
The authors thank Dr. Zeinab Nawito for contributions in
the finalization of this work regarding grammatical
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