Is a routine voiding cystourethrogram necessary in children after the first febrile urinary tract infection?

Lee, Jun Ho; Kim, Moon Kyu; Park, Sung Eun

doi:10.1111/j.1651-2227.2011.02507.x

Cited by 38 publications

(24 citation statements)

References 21 publications

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“…It can also predict who is less likely to develop renal scarring in febrile UTI patients. Usefulness of DMSA scan in febrile UTI has been documented by other researchers as well [11][12][13][14][15][16][17][18][19] and has been endorsed by AAP, who now recommend it in all children < 24 months with first febrile UTI. However, routine use of this imaging during acute illness does not alter treatment in the majority of cases and it does not predict who exactly is going to develop scarring.…”

Section: Discussionmentioning

confidence: 96%

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Role of Various Imaging Modalities After a First Febrile Urinary Tract Infection in Young Children

Kawoosa¹,

Ali²,

Kubran³

2018

jemds

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BACKGROUND UTI in the paediatric population is well-recognised as the cause of acute morbidity and chronic medical conditions such as hypertension and renal insufficiency in adulthood. 1 The goal of imaging studies in children with UTI is to identify anatomic abnormalities that predispose to infection, determine whether there is active renal involvement and to assess whether renal function is normal or at risk. Aims and Objectives- To measure the incidence of renal scarring in patients admitted with first febrile UTI.  To list renal image findings in patients with first febrile UTI, 1 -36 months of age. MATERIALS AND METHODSA total of 108 patients, 1 -36 months of age, coming with first febrile UTI, either admitted or on an outpatient department basis during one and a half years, who satisfy the inclusion criteria were studied. Renal scanning with technetium-99m labeled dimercaptosuccinic acid and renal ultrasonography were performed in the acute phase to determine the presence or absence of acute pyelonephritis and anatomical abnormalities, respectively. Contrast voiding cystourethrography was performed approximately one month after diagnosis in those with abnormal ultrasound or abnormal DMSA. Technetium-99m labeled dimercaptosuccinic acid renal scanning was repeated six months later to determine the incidence and severity of renal scarring. Age groups, sex, VCUG, renal ultrasonography and DMSA renal scintigraphy results were analysed. RESULTSOut of 108 patients, RBUS was normal in 63 (58%) and abnormal in 45 (42%). Sonogram showed changes consistent with acute pyelonephritis in 27.7% (30/108) of the whole group and in only 57.7% (30/52) of the patients with scintigraphically documented acute pyelonephritis. DMSA was suggestive of acute pyelonephritis in 52 (48%) patients in acute stage and of renal scarring in 22 (20%) at 6 months. All patients who had scarring at 6 months had abnormal initial scan. Out of 69 patients with abnormal ultrasonography or scanning who were subjected to VCUG, 39 had vesicoureteral reflux (56.5%). Renal scarring was more likely to occur in children with documented VUR than those without VUR (17/39 vs. 5/30). Among the patients with VUR, scarring was seen more likely in patients with higher grades of VUR. CONCLUSIONThe renal ultrasound is of limited value in febrile UTI, especially at places where DMSA scanning is available. The use of DMSA during acute illness identifies patients with acute pyelonephritis who are at risk of development of renal scarring later in life. VCUG may demonstrate a relationship between VUR and renal inflammation and identify high-risk group for development of renal scarring. KEYWORDSUrinary Tract Infection, VUR, DMSA Scan. HOW TO CITE THIS ARTICLE: Kawoosa KM, Ali SW, Kubran SH. Role of various imaging modalities after a first febrile urinary tract infection in young children. J. Evolution Med. Dent. Sci. 2018;7(11):1404-1408, DOI: 10.14260/jemds/2018/319 BACKGROUND UTI in the paediatric population is well-recognised as a cause of acute morbidity ...

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Section: Discussionmentioning

confidence: 96%

“…11 Though VUR is also an established important factor in genesis of renal scarring and thereafter hypertension and end stage renal disease, routine use of VCUG in febrile UTI has been questioned by many. 3,17,18,19,21 However, further research is needed.…”

Section: Discussionmentioning

confidence: 99%

Role of Various Imaging Modalities After a First Febrile Urinary Tract Infection in Young Children

Kawoosa¹,

Ali²,

Kubran³

2018

jemds

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“…Sensitivity has been reported from 18–79% and specificity from 41–99% [4, 5, 15–18]; these papers have tended to use different definitions of a positive RBUS (or no definition at all) and looked at varying VCUG outcomes. Much of the published literature is limited by verification bias (by which only some of the eligible participants underwent both RBUS and VCUG, often because the first study performed was normal) [4, 19, 20]. The current study is unique, in that it included a large sample of patients who underwent both RBUS and VCUG on the same day, with neither test being contingent on the findings of the first test performed.…”

Section: Discussionmentioning

confidence: 99%

Predictive value of specific ultrasound findings when used as a screening test for abnormalities on VCUG

Logvinenko

Chow

Nelson

2015

Journal of Pediatric Urology

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Summary Background Renal and bladder ultrasound (RBUS) is often used as an initial screening test for children after urinary tract infection (UTI). The 2011 AAP guidelines specifically recommend that RBUS be performed first, with voiding cystourethrogram (VCUG) to be performed only if the ultrasound is abnormal. While prior research has suggested that RBUS is neither sensitive nor specific for VCUG findings, such as vesicoureteral reflux (VUR), it is uncertain as to whether specific RBUS findings, alone or in combination, might make RBUS more useful as a predictor of VCUG abnormalities. Aims To evaluate the association of specific RBUS with VCUG findings, and determine whether predictive models that accurately predict patients at high risk of VCUG abnormalities, based on RBUS findings, can be constructed. Methods and study sample A total of 3995 patients were identified with VCUG and RBUS performed on the same day. The RBUS and VCUG reports were reviewed and the findings were classified. Analysis was limited to patients aged 0–60 months with no prior postnatal genitourinary imaging and no history of prenatal hydronephrosis. Analysis The associations between large numbers of specific RBUS findings with abnormalities seen on VCUG were investigated. Both multivariate logistic models and a neural network machine learning algorithms were constructed to evaluate the predictive power of RBUS for VCUG abnormalities (including VUR or bladder/urethral findings). Sensitivity, specificity, predictive values and area under receiving operating curves (AUROC) of RBUS for VCUG abnormalities were determined. Results A total of 2259 patients with UTI as the indication for imaging were identified. The RBUS was reported as “normal” in 75.0%. On VCUG, any VUR was identified in 41.7%, VUR grade >II in 20.9%, and VUR grade >III in 2.8%. Many individual RBUS findings were significantly associated with VUR on VCUG. Despite these strong univariate associations, multivariate modeling didn’t result in a predictive model that was highly accurate. Multivariate logistic regression built via stepwise selection had: AUROC=0.57, sensitivity=86% and specificity=25% for any VUR; AUROC=0.60, sensitivity=5% and specificity=99% for VUR grade >II; and AUROC=0.67, sensitivity=6% and specificity=99% for VUR grade >III. The best predictive model constructed via neural networks had: AUROC=0.69, sensitivity=64% and specificity=60% for any VUR; AUROC=0.67, sensitivity=18% and specificity=98% for VUR grade >II; and AUROC=0.79, sensitivity=32% and specificity=100% for VUR grade >III. Conclusions Even with the state-of-the-art predictive models, abnormal findings on RBUS provide a poor screening test for genitourinary abnormalities. Renal bladder ultrasound and VCUG should be considered complementary, as they provide important, but different, information.

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“…Sensitivity has ranged from 18% to 79% and specificity from 41% to 99%, depending on how a "positive" RBUS was defined and what VUR outcome was assessed (eg, any VUR, "dilating VUR," "high-grade VUR"). [6][7][8][9][10][11] Many other groups have reported GU imaging findings among children who have a history of UTI. However, most of these papers have limitations that make it impossible to determine the test characteristics of RBUS; most common is that many studies do not provide sufficient data to directly compare RBUS findings with VCUG findings in individual patients.…”

Section: Discussionmentioning

confidence: 99%

“…Many studies have similar limitations. 6,7,9,19,24 Other studies have limited generalizability owing to narrow 10,25 or broad [26][27][28] age ranges, or small sample size. 8,[26][27][28] One study looked specifically at the predictive value of ureteral dilation as an isolated finding on RBUS.…”

Section: Discussionmentioning

confidence: 99%

Ultrasound as a Screening Test for Genitourinary Anomalies in Children With UTI

2014

PEDIATRICS

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METHODS:We analyzed 3995 clinical encounters from January 1, 2006 to December 31, 2010 during which VCUG and RBUS were performed for history of UTI. Patients who had previous postnatal genitourinary imaging or history of prenatal hydronephrosis were excluded. Sensitivity, specificity, and predictive values of RBUS for VCUG abnormalities were determined. RESULTS:We identified 2259 patients age ,60 months who had UTI as the indication for imaging. RBUS was reported as "normal" in 75%. On VCUG, any vesicoureteral reflux (VUR) was identified in 41.7%, VUR grade .II in 20.9%, and VUR grade .III in 2.8%. Sensitivity of RBUS for any abnormal findings on VCUG ranged from 5% (specificity: 97%) to 28% (specificity: 77%). Sensitivity for VUR grade .III ranged from 18% (specificity: 97%) to 55% (specificity: 77%). Among the 1203 children aged 2 to 24 months imaged after a first febrile UTI, positive predictive value of RBUS was 37% to 47% for VUR grade .II (13% to 24% for VUR grade .III); negative predictive value was 72% to 74% for VUR grade .II (95% to 96% for VUR grade .III).

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Is a routine voiding cystourethrogram necessary in children after the first febrile urinary tract infection?

Cited by 38 publications

References 21 publications

Role of Various Imaging Modalities After a First Febrile Urinary Tract Infection in Young Children

Role of Various Imaging Modalities After a First Febrile Urinary Tract Infection in Young Children

Predictive value of specific ultrasound findings when used as a screening test for abnormalities on VCUG

Ultrasound as a Screening Test for Genitourinary Anomalies in Children With UTI

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