Accuracy of Early DMSA Scan for VUR in Young Children With Febrile UTI

Zhang, Xin; Xu, Hong; Zhou, Lijun; Cao, Qi; Shen, Qian; Sun, Li; Fang, Xiaoyan; Guo, Wei; Zhai, Yi­hui; Rao, Jia; Pa, Mier; Zhao, Ruifang; Bi, Yunli

doi:10.1542/peds.2012-2650

Cited by 40 publications

(30 citation statements)

References 27 publications

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“…Among 151 patients with dilating VUR, 149 (98.7%) had abnormal acute-phase renal scans yielding a sensitivity of 96.15% and a positive predictive value (PPV) of 34%. Overall, 46 patients (8.8%) had scars on delayed DMSA scans [14]. It can be gleaned from these studies and some others that DMSA can be used as an effective screening tool to identify patients who are likely to have dilating VUR and UTI recurrence.…”

Section: The Top-down Approachmentioning

confidence: 99%

“…Although TDA could detect clinically-significant VUR with a sensitivity of 85%–96% [13142122], the low specificity and modest PPV of TDA does not justify the prohibitive cost and the unnecessary ionizing radiation exposure to all children after febrile UTIs should the TDA be universally adopted. Bearing in mind that 85% of children with symptomatic or febrile UTI will never experience UTI recurrence [23], only 15% would benefit from further testing and possible treatment.…”

Section: The Top-down Approachmentioning

confidence: 99%

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Critical appraisal of the top-down approach for vesicoureteral reflux

Abdelhalim

Khoury

2017

Investig Clin Urol

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Vesicoureteral reflux (VUR) has been linked to recurrent urinary tract infections (UTIs), renal scarring, hypertension, renal insufficiency and end-stage kidney disease. Different imaging strategies have been proposed to approach children presenting with UTI to sort out patients with significant VUR while minimizing patient morbidity, radiation exposure and financial burden. None of these imaging strategies is universally accepted. The“top-down approach” (TDA) aims at restricting the number of voiding cystourethrograms (VCUGs) and its associated morbidity while identifying patients with clinically-significant reflux. In this approach, children presenting with febrile UTIs are acutely investigated with dimercapto-succinic acid (DMSA) renal scans to identify patients with renal parenchymal inflammation. Those with evidence of renal affection are offered VCUG and late DMSA scan to identify VUR and permanent renal scarring, respectively. Although TDA could identify clinically-significant VUR with high sensitivity, it is not without limitations. The approach segregates patients based on the presence of DMSA cortical lesions omitting the morbidity and the economic burden of UTI. Additionally, some of DMSA lesions are attributed to congenital dysplasia and unrelated to UTI. Ionizing radiation exposure, financial costs, limited availability of DMSA scans in the acute setting, variability in interpreting the results and low yield of actionable findings on DMSA scans are some other limitations. In this review, we tried to address the drawbacks of the TDA and reinforce the value of patient-centered approach for VUR.

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Section: The Top-down Approachmentioning

confidence: 99%

Section: The Top-down Approachmentioning

confidence: 99%

Critical appraisal of the top-down approach for vesicoureteral reflux

Abdelhalim

Khoury

2017

Investig Clin Urol

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“…The majority will have a normal scan and among these few will present a recurrence. The strength of this study is to have linked abnormal DSMA with risk of recurrent UTI as most previous studies have focused on the relationship between results of various diagnostic tests and the presence or absence of VUR or probability of resolution of VUR [6][7][8][9][10][11][12][13][14][15][16].…”

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confidence: 99%

Children with abnormal DMSA nuclear scan present a higher risk of recurrent febrile urinary tract infections

et al. 2018

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The ideal management of a child presenting a first episode of febrile urinary tract infection is still under debate. In the recent guidelines for the diagnosis and management of urinary tract infections (UTI) in children, the American Association of Pediatrics recommend performing a post-UTI sonography, and if there are abnormal findings, a voiding cystourethrogram [1]. This change derives from the understanding that we should be avoiding renal damage rather more than diagnosing reflux, since both surgery and antibiotic prophylaxis are progressively being abandoned for most cases of vesicoureteral reflux (VUR) [2,3]. The most significant event which will bring a child to active management is recurrence of UTI [4,5]. It seems therefore more clinically relevant to differentiate between children who will suffer recurrent episodes of UTI and those who will not, rather than to simply identify which children have VUR. We therefore aimed to evaluate if DMSA nuclear scan could reliably identify which children were at risk of presenting a second febrile UTI.We retrospectively analyzed all children aged between 2 and 24 months, without prenatally diagnosed uropathy, who were admitted to our institution for a first febrile UTI between 2009 and 2013, had a post-urinary tract infection sonography and DMSA nuclear scan, and were followed for at least 24 months. We excluded patients with missing or incomplete data, or lost to follow-up. Febrile UTI was defined as fever > 38 °C associated with positive urinalysis and urine culture (> 10 5 CFU/mL urine) collected through catheterization in girls, and clean-catch in boys. We noted patient's characteristics, and the results of the DMSA scan performed within 1 month of the acute episode. DMSA scans were categorized as normal, i.e., no scarring or dysplasia, or abnormal, any degree of scarring or dysplasia, functional impairment or atrophy.After the first febrile UTI, parents were systematically counseled about early diagnosis and having a urinalysis done if their child presented unexplained fever. None were given antibiotic prophylaxis but they were given advice about local hygiene and measures to avoid constipation in their child. All children were followed at least once every 6 months for a minimum of 24 months. The main outcome was recurrence of a second febrile UTI within the first 24 months of follow-up. In case of recurrence, a cystogram was performed, and children were further managed accordingly.On hundred and seven children were included in our study. There were 49 boys and 58 girls (45.8/54.2%). None were lost to follow-up, and all relevant data were available for all included patients. Children included did not differ from those who were excluded from the study. The mean age at first febrile UTI was 6.8 ± 5.4 months. Twenty-four (22.4%) children presented abnormal DMSA findings. Six presented asymmetric function without signs of dysplasia or scarring, two had a solitary kidney, and 16 had signs of dysplasia or scarring, of which 6 had asymmetric function. Sixteen (14.9%)...

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“…The acquisition of renal scarring through the association of reflux, urinary infection, and intrarenal reflux has been observed clinically and experimentally. 19,20 Nuclear scintigraphy can detect areas of acute renal inflammation and chronic scarring, and this capability has changed imaging of pediatric UTIs. In our study, DMSA findings showed that 23.5% of the children (33 0f 140) had renal scarring.…”

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confidence: 99%

Microbiological Profile of Urinary Tract Infection in Children With Vesicoureteric Reflux and Comparison of E Coli and Non-E Coli Infections.

Nazir¹,

KhursheedAhmad²,

Lone³

et al. 2017

IJAR

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Background:The urinary tract is a common site of infection in the paediatric population. Vesicouretric reflux (VUR) refers to the retrograde passage of urine from the bladder into the ureter. A high incidence of VUR is reported in patients undergoing evaluation for UTI. The aetiology of paediatric UTI and the antibiotic susceptibility of urinary pathogens in both the community and hospitals have been changing, and drug resistance has become a major problem. With this background, the present study was conducted to observe the profile of the paediatric UTI, to find out the bacterial pathogens involved and their antimicrobial susceptibility pattern in patients with VUR and consecutive renal scarring in these patients at a tertiary care centre in North India. Material and Method: All patients from 0-15 years of age diagnosed with urinary tract infection and vesicoureteral reflux attending the OPD and admitted in the hospital were included in the study. Urine was inoculated on Hicrome agar using a calibrated loop the plates were examined after 24 hours for colony morphology, significant colony count, and their characteristics. Patients underwent VCUG and DMSA scan when indicated. Results: Overall males were more affected than females. E Coli was the commonest organism grown on culture. Quinolones, cotrimoxazole and amoxicillin were among the less effective drugs where as nitrofurantoin, aminoglycosides were highly effective drugs. Renal scars were more commonly seen in higher grade of reflux whereas there was no difference in scarring in E Coli vs Non E Coli infections. Conclusion: Cotrimoxazole should not be used for antimicrobial prophylaxis where as nitrofurantoin is a better option for prophylaxis. Aminoglycosides can be used as empirical therapy till the results of antimicrobial sensitivity are available. Renal scars are seen more often in higher grades of vesicoureteric reflux and thus need to be treated aggressively.

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Accuracy of Early DMSA Scan for VUR in Young Children With Febrile UTI

Cited by 40 publications

References 27 publications

Critical appraisal of the top-down approach for vesicoureteral reflux

Critical appraisal of the top-down approach for vesicoureteral reflux

Children with abnormal DMSA nuclear scan present a higher risk of recurrent febrile urinary tract infections

Microbiological Profile of Urinary Tract Infection in Children With Vesicoureteric Reflux and Comparison of E Coli and Non-E Coli Infections.

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