Özgüe ÇAĞLAR, Sibel YEL, Hülya NALCACIOĞLU, Binnaz ÇELİK, Funda BAŞTUĞ

Clinical value of late DMSA scan in predicting vesicoureteral reflux in children with febrile urinary tract infection

Aim: To assess the usefulness of late dimercaptosuccinic acid (DMSA) renal scans in revealing high-grade vesicoureteral reflux(VUR).Material and Methods: Between July 2015 and December 2016, medical records of 112 patients who were admitted with febrileurinary tract infections (fUTIs) were retrospectively reviewed. The demographic information of the patients, and follow-up imaging[ultrasonography (USG), DMSA renal scans, and voiding cystourethrography] data were reviewed.Results: Of the 112 patients, 82 patients (73.2%) were female, 30 were male (26.8%), and the mean age was 7.04 ± 3.94 years.Recurrent fUTIs were detected in 65 patients (58%). Of the patients, 68 (60.7%) had abnormal urinary system USG, and 74 (66.1%)had abnormal DMSA renal scans. Vesicoureteral reflux (VUR) was detected in 63 patients (56.3%). VUR was present in 49 (66.2%) of74 patients with scarring in DMSA and detected in 14 (38.8%) of 38 patients with normal DMSA scans. Significant agreement (kappa:0.274 / p=0.003) was found between DMSA and VUR results. The sensitivity, specificity and positive predictive values of late DMSArenal scan to predict VUR were 77.8 %, 49 % and 63.2% respectively.Conclusion: Abnormal late DMSA scans carry a higher sensitivity and positive predictive value for predicting high-grade VUR inchildren with recurrent fUTIs. Late DMSA imaging seems a useful option in screening for high-grade VUR in children when the acuteinterventions are limited.

PDF

___

1. Montini G, Tullus K, Hewitt I. Febrile Urinary Tract Infections in Children. N Engl J Med. 2011;365:239- 50.
2. Baumer JH, Jones RW. Urinary tract infection in children, National Institute for Health and Clinical Excellence. Arch Dis Child Educ Pract Ed 2007;92:189- 92
3. Paintsil E. Update on recent guidelines for the management of urinary tract infections in children: the shifting paradigm. Curr Opin Pediatr 2013;25:88- 94.
4. KoyleMA, Elder JS, Skoog SJ, et al. Febrile urinary tract infection, vesicoureteral reflux, and renal scarring: current controversies in approach to evaluation. Pediatr Surg Int 2011;27:337-46.
5. Lebowitz RL, Olbing H, Parkkulainen KV, et al. International system of radiographic grading of vesicoureteric reflux. International reflux study in children. Pediatr Radiol 1985;15:105-9.
6. Lee MD, Lin CC, Huang FY, et al. Screening young children with a first febrile urinary tract infection for high-grade vesicoureteral reflux with renal ultrasound scanning and technetium-99m-labeled dimercaptosuccinic acid scanning. J Pediatr 2009; 154:797-802.
7. Herz D, Merguerian P, McQuiston L, et al. 5-year prospective results of dimercapto-succinic acid imaging in children with febrile urinary tract infection: proof that the top-down approach works. J Urol 2010; 184:1703-9.
8. Park YS. Renal scar formation after urinary tract infection in children. Korean J Pediatr 2012;55:367- 70.
9. Pohl HG, Belman AB. The “top-down” approach to the evaluation of children with febrile urinary tract infection. Adv Urol 2009:783409.
10. Preda I, Jodal U, Sixt R, et al. Normal dimercaptosuccinic acid scintigraphy makes voiding cystourethrography unnecessary after urinary tract infection. J. Pediatr 2007;151:581-4.
11. Tekgül S, Riedmiller H, Hoebeke P, et al. European Association of Urology. EAU guidelines on vesicoureteral reflux in children. Eur Urol 2012; 62:534-42.
12. Hansson S, Dhamey M, Sigström O, et al. Dimercaptosuccinic acid scintigraphy instead of voiding cystourethrography for infants with urinary tract infection. J Urol 2004;172:1071-3.
13. Hoberman A, Charron M, Hickey RW, et al. Imaging studies after a first febrile urinary tract infectionin young children. N Engl J Med 2003;348:195-202.
14. Montini G, Zucchetta P, Tomasi L, et al. Value of imaging studies after a first febrile urinary tract infection in young children: datafrom Italian renal infection study. Pediatrics 2009;123:239-46.
15. Mahant S, Friedman J, Mac Arthur C. Renal ultrasound findings and vesicoureteral reflux in children hospitalized with urinary tract infection. Arch Dis Child 2002;86:419-20.
16. Shaikh N, Hoberman A, Rockette HE, et al. Identifying children with vesicoureteral reflux: a comparison of 2 approaches. J Urol. 2012;188:1895-9.
17. Wongbencharat K, Tongpenyai Y, Na-Rungsri K. Renal ultrasound and DMSA screening for high-grade vesicoureteral reflux. Pediatr Int 2016;58:214-8.
18. Riccabona M, Avni FE, Blickman JG, et al. Imaging recommendations in paediatric uroradiology: minutes of the ESPR workgroup session on urinarytract infection, fetal hydronephrosis, urinary tract ultrasonography and voiding cystourethrography, Barcelona, Spain, June2007. Pediatr Radiol 2008;38: 138-45.
19. Keren R. Imaging and treatment strategies for children after first urinary tract infection. Curr. Opin. Pediatr. 2007;19:705-10.
20. Tsai JD, Huang CT, Lin PY et al. Screening high-grade vesicoureteral reflux in young infants with a febrile urinary tract infection. Pediatr. Nephrol 2012;27:955- 63.
21. Lee HY, Soh BH, Hong CH, et al. The efficacy of ultrasound and dimercaptosuccinic acid scan in predicting vesicoureteral reflux in children below the age of 2 years with their first febrile urinary tract infection. Pediatr. Nephrol 2009;24:2009-13.
22. Lee MD, Lin CC, Huang FY, et al. Screening young children with a first febrile urinary tract infection for high-grade vesicoureteral reflux with renal ultrasound scanning and technetium-99m-labeled dimercaptosuccinic acid scanning.J. Pediatr 2009; 154:797-802.
23. Hansson S, Dhamey M, Sigström O, et al. Dimercaptosuccinic acid scintigraphy instead of voiding cystourethrography for infants with urinary tract infection. J Urol 2004;172:1071-3.
24. Tseng MH, Lin WJ, Lo WT, et al. Does a normal DMSA obviate the performance of voiding cystourethrography in evaluation of young children after their first urinary tract infection? J Pediatr 2007;150:96-9.
25. Shaikh N, Spingarn RB, HumSW. Dimercaptosuccinic acid scan or ultrasound in screening for vesicoureteral reflux among children with urinary tract infections. Cochrane Database Syst Rev. 2016;7:CD010657
26. Fouzas S, Krikelli E, Vassilakos P, et al. DMSA scan for revealing vesicoureteral reflux in young children with urinary tract infection. Pediatrics 2010;126:513-9.
27. Quirino IG, Silva JM, Diniz JS, et al. Combined use of late phase dimercapto-succinic acid renal scintigraphy and ultrasound as firstline screening after urinary tract infection in children. J Urol 2011;185:258-63.
28. Jakobsson B, Svensson L. Transient pyelonephritic changes on 99m Technetium-dimercaptosuccinic acid scan for at least five months after infection. Acta Paediatr 1997;86:803-7.
29. Snodgrass WT, Shah A, Yang M, et al. Prevalence and risk factors for renal scars in children with febrile UTI and/or VUR: a cross-sectional observational study of 565 consecutive patients. J Pediatr Urol 2013;9:856- 63.
30. Ascenti G, Zimbaro G, Mazziotti S, et al. Vesicoureteral reflux: comparison between urosonography and radionuclide cystography. Pediatr Nephrol 2003;18: 768-71.