Renal damage detected by DMSA, despite normal renal ultrasound, in children with febrile UTI

Bush, Nicol; Keays, Mélise; Adams, Christina; Mizener, K.; Pritzker, Karen; Smith, W. G.; Traylor, Janelle; Villanueva, Carlos; Snodgrass, Warren

doi:10.1016/j.jpurol.2015.01.011

Cited by 44 publications

(32 citation statements)

References 15 publications

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“…Of 512 patients with normal renal bladder ultrasound (RBUS) enrolled in their study, 19% had renal abnormalities on DMSA. VUR was identified in 76% of them [34]. In agreement with the previous studies, ultrasound was found to be less sensitive and specific than DMSA-single-photon emission computed tomography (CT), gadolinium-enhanced magnetic resonance imaging and spiral CT for diagnosing pyelonephritis in an animal study using histopathologic examination as the standard of reference [35].…”

Section: What Is the Best Initial Imaging Study After The First Futi:supporting

confidence: 72%

“…In another study, 24% of patients with a normal ultrasound after the first FUTI had a dilating VUR [33]. Similarly, Bush et al [34] reported poor sensitivity (34%) and limited positive predictive value (47%) of renal ultrasound to identify renal damage after FUTIs. Of 512 patients with normal renal bladder ultrasound (RBUS) enrolled in their study, 19% had renal abnormalities on DMSA.…”

Section: What Is the Best Initial Imaging Study After The First Futi:mentioning

confidence: 99%

“…Some authors adopted a modified approach. This approach entails an acute RBUS and delayed DMSA after FUTI, reserving VCUG for patients with abnormal DMSA, RBUS and/or recurrent FUTI [34]. Patients diagnosed with VUR should be managed according the risk-stratified approach.…”

Section: Acute Versus Delayed Scansmentioning

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: What Is the Best Initial Imaging Study After The First Futi:supporting

confidence: 72%

Section: What Is the Best Initial Imaging Study After The First Futi:mentioning

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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“…In accordance with this imaging strategy, some studies reported that a single DMSA study (≥3 months after the latest episode of fUTI) was used in children referred for assessment of the first or recurrent episodes of fUTI. [21,22] The recent pediatric guidelines published by The European Association of Urology and European Society for Paediatric Urology have also recommended that DMSA scanning should be performed within 1-2 months of the UTI episode, except for neonates. [23] In line with the literature, US alone had a low diagnostic value for prediction of VUR in our study.…”

Section: Discussionmentioning

confidence: 99%

Delayed diagnosis of primary vesicoureteral reflux in children with recurrent urinary tract infections: Diagnostic approach and renal outcomes

Doğan

Koyun

Aksoy

et al. 2018

Turkish Journal of Urology

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Objective: In this study, we aimed to assess renal outcomes of delayed diagnosis of dilating primary vesicoureteral reflux (VUR) following recurrent febrile urinary tract infections (fUTIs) and its diagnostic imaging procedures. Material and methods:The medical records of patients who underwent ultrasonography (US), non-acute dimercaptosuccinic acid (Tc-99mDMSA) scintigraphy and voiding cystourethrography (VCUG), and who were older than 2 years at the time of VUR diagnosis were retrospectively reviewed.Results: A total of 32 children (female, n=27: 84.4%) with a mean age of 7.67±3.34 years at the time of diagnosis of VUR were included in the study. Grade III, IV, V VUR were found in 22%, 69%, and 9% of the patients, respectively. At the time of VUR diagnosis, abnormal US findings were detected in 75% of the cases. Tc-99mDMSA detected abnormalities in 83.9% (7 with a single scar, 7 with multiple lesions, 12 with reduced kidney function) of the patients. Estimated glomerular filtration rate of 3 patients with bilateral grade IV VUR was <75 mL/min/1.73 m 2 . In 5 patients (16%), VUR could not be predicted by US+DMSA scintigraphy (Grade IV VUR in 3 and Grade III in 2 cases ). The sensitivity in predicting VUR was 75.00% , respectively, for US alone and combined US+DMSA. Conclusion:VCUG should be performed routinely in addition to US and non-acute DMSA in all children referred with recurrent fUTIs. Awareness of childhood UTI in public and healthcare personnels should be increased in order to refer these patients at a early stage to pediatric urology and nephrology units.

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“…Bush y col. hallaron nefroesclerosis mediante gammagrafía con DMSA en 99 de 512 pacientes después de una IU febril con ecografía normal y concluyeron que la capacidad de la ecografía para detectar daño renal era baja. 19 En otro metanálisis se determinó que, en comparación con la gammagrafía con DMSA, la ecografía tenía una sensibilidad del 37% al 100% y una especificidad del 65% al 99% debido al hecho de que la ecografía depende de la interpretación personal. 20 De manera similar a los resultados de varios estudios previos, en este estudio se determinó que el poder de la ecografía era débil.…”

Section: Discussionunclassified

Asociación entre el reflujo vesicoureteral y la nefroesclerosis en las infecciones urinarias

2018

Arch Argent Pediatr

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Arch Argent Pediatr 2018;116(4):e542-e547 / e542Asociación entre el reflujo vesicoureteral y la nefroesclerosis en las infecciones urinarias Conflicto de intereses:Ninguno que declarar.Recibido: 19-10-2017 Aceptado: 19-2-2018 RESUMEN Introducción. El objetivo del estudio fue investigar la relación entre reflujo vesicoureteral (RVU) y daño renal en pacientes con infección urinaria (IU) sin fiebre, primera IU febril e IU recurrente. El objetivo secundario, determinar si la proteína C-reactiva (PCR) actuaría como predictor de nefroesclerosis en las IU febriles. Población y métodos. Estudio prospectivo; pacientes pediátricos con IU sin fiebre, primera IU febril e IU recurrente. Los análisis de laboratorio de rutina incluyeron hemograma completo, urea, creatinina, análisis de orina completamente automatizado, urocultivo y PCR. Se realizó ecografía urológica luego del diagnóstico de IU, cistouretrografía miccional tras seis semanas y gammagrafía renal estática con ácido dimercaptosuccínico marcado con 99mTc tras seis meses a todos los participantes. Resultados. Participaron 47 niños con IU sin fiebre, 48 con primera IU febril y 61 con IU recurrente. Hubo una diferencia estadísticamente significativa entre los grupos respecto de RVU y nefroesclerosis (p= 0,001 y p= 0,011, respectivamente). También hubo una diferencia estadísticamente significativa respecto de nefroesclerosis entre los pacientes con y sin RVU (p= 0,001). Además, se estableció una diferencia estadísticamente significativa respecto de nefroesclerosis (p < 0,05) en los pacientes con PCR cinco veces mayor o menor que el valor de corte aceptado (5 mg/dl). Conclusión. La proporción de nefroesclerosis fue paralela a la frecuencia de RVU. Cuanto mayor era el grado de RVU, mayor era el daño renal. Se determinó una correlación positiva entre PCR elevada y nefroesclerosis, lo que señala esclerosis durante el diagnóstico de pielonefritis. INTRODUCCIÓNLas infecciones urinarias, en especial en los niños menores de t r e s a ñ o s , s e e n c u e n t r a n e n t r e las infecciones bacterianas más frecuentes. 1 En el 10% al 64% de los casos de pielonefritis aguda (PA) se notifica daño del parénquima renal, con casos de pacientes con infección recurrente y tratamiento inadecuado que presentan riesgos de morbilidad, tales como hipertensión e insuficiencia renal crónica (IRC). 2 El reflujo vesicoureteral (RVU) es la anomalía detectada con más frecuencia en los pacientes pediátricos con infección urinaria (IU), con una incidencia del 30% al 50%, mientras que se observa nefroesclerosis en el 30% al 40% de los pacientes. 3,4 Por lo tanto, es necesario estudiar cada caso de IU pediátrica para determinar la presencia de RVU. A c t u a l m e n t e , l a g a m m a g r a f í a con ácido dimercaptosuccínico (dimercaptosuccinic acid, DMSA) es la mejor técnica de diagnóstico por imágenes disponible para detectar lesiones renales asociadas con la pielonefritis aguda. 5 Se ha informado que la lesión renal detectada por g a m m a g r a f í a c o n D M S A e n e l transcurso de una p...

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Renal damage detected by DMSA, despite normal renal ultrasound, in children with febrile UTI

Cited by 44 publications

References 15 publications

Critical appraisal of the top-down approach for vesicoureteral reflux

Critical appraisal of the top-down approach for vesicoureteral reflux

Delayed diagnosis of primary vesicoureteral reflux in children with recurrent urinary tract infections: Diagnostic approach and renal outcomes

Asociación entre el reflujo vesicoureteral y la nefroesclerosis en las infecciones urinarias

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